Fraser form 2015 .pdf

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Original filename: Fraser form 2015.pdf
Author: Mel McGregor

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Environment Program Attendance Form
Clean up Australia Day Fraser Island – 27 Feb – 1 March 2015
Please have this form and payment back by Feb 6th
Email return: smileyman3000@gmail.com
First name:_________________ Last name:_________________ DOB:____________
Group/crew affiliation:_____________ Position: Rover__ Leader__ Other__ (Tick one)
Home address:___________________________________________________________
Contact number:___________________
COST: MUST BE PAID FOR BY FEB 6 (Contact us if this is an issue)
$75 (includes fuel for vehicles, camping for two nights, three meals, barge fees).
Account name: Fitzroy Rover Crew BSB: 064-709 Account Number: 10354445
Cheques payable to Fitzroy Rover Crew
Emergency contact:
First name:_________________ Last name:_________________ Relationship:___________
Contact number:___________________
Medical information:
Do you have a medical condition we need to be aware of? ______ if yes, please provide
details_____________________________________________________________________
Do you have any allergies to food/other?__________________________________________
Medicare number:___________________ Date of last Tetanus injection:________________
Vehicles: (Chosen drivers will have been notified by us)
Vehicle make/model:__________________ Registration:__________(must be registered)
Seating capacity_____ Fuel type:____________
I will/will not be contactable by radio at the event (please indicate)
I am/am not an experienced beach and 4x4 driver (please indicate)
I have/do not have my own rescue equipment (please indicate)
All vehicles MUST be contactable by radio/mobile during the activity.
I do/do not want to purchase a t-shirt for $25. Please indicate size: _____ (XS-XXXL)

I, ____________________ will be attending Clean Up Australia Day on Fraser Island (2015).
(if applicable) I am aware that the safety of participants in my vehicle is my responsibility;
and understand that responsible use of my vehicle is ultimately at the discretion of the
organisers and 4x4 guides. I understand that unsafe use of any vehicle during the activity is
illegal and will not be tolerated, and will result in immediate removal from the activity.
I understand that, as an adult member of Scouting, I am bound by the Scout Law and am
solely responsible for my actions throughout the event.
Signed:_________________________

Date:________________


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