Rotary Youth Program of Enrichment D9600 2017 Application Form
When: 11th, 12th & 13th of August 2017
Where: Cross Ridge, Luther Heights, David Low Way, Coolum
Applications close: Friday the 28th of July
Contact us at: 0431 103 274 or christopherpoole1995@gmail.com
Email address *
Please fill out the below table to complete your application:
Full Name *
Your answer
Preferred Name
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Email Address
Your answer
Parents/ Guardians Email Address *
Your answer
School *
Your answer
Year Level *
Your answer
Parent/ Guardian's Name *
Your answer
Parent/ Guardian's Phone Number *
Your answer
Sponsor Rotary Club *
Your answer
Other Details:
Shirt Size (Mens Sizing) *
Special Requests - Physical, Dietary or Allergies
Your answer
Medicare Number *
Your answer
Doctor Details *
Your answer
Private Health Care (if applicable)
Your answer
Travel Arrangements *
Travel Arrangements:
For the participants travelling by bus, we would like you to be at your designated stop at least 15 minutes before the departure time.

The camp is expected to finish at 2:30pm on the Sunday. For the return bus trip, the expected times of arrival are:

Arrival:
Departure:
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