MUOC Membership form 2017
Check that you have all required information for this page before you start. Any information provided will remain confidential and only used for club administration purposes.
First Name
Your answer
Last Name
Your answer
Date of Birth
Day/Month/Year
Your answer
Email address
Your answer
Mobile Number
Your answer
Address
Your answer
Emergency Contact Name
(Who you would like us to contact in case of injury etc. Please choose someone living in Australia, who is not going to be attending MUOC activities, if possible)
Your answer
Emergency contact number
Your answer
Do you have any First Aid qualifications?
Please state the highest current level
Your answer
Student Number
Type "NA" if not a student
Your answer
Student
Student
Do you have any medical conditions that could affect you on a MUOC activity?
All medical information is confidential, and will only be used by Club leaders to assess trip safety and ensure reasonable preparations are made so that appropriate medical care is available during trips.
Required
Please elaborate on any conditions from above
Include severity, action plan, medication, and any other relevant information. If multiple answers were selected, please separate with a blank line.
Your answer
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