Canberra Physical Culture Club (CPCC)

Enrolment form 2018

First Name *
Surname *
Date of Birth *

/ /
Email *
Address *
Phone *
Alternative Phone
Vikings Membership Number
I have / My child has injuries/health issues

Yes
I have emailed the details and action plan for any injuries/health issues to canberraphysi@hotmail.com

Yes
I give permission for my or my child's photo to be used for advertising for our club either on our website or in print

Yes
Have you / your child previously been a member

Yes
Parent's / Guardian's Name (if under 16)
Security Code: *
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