Family Application Form
Port Macquarie Pacers Running Club Incorporated Family Members Application Form
Email address *
Memberships run 1-September to 31 August. Family memberships vary in price, and are based on how many singlets you are after. We require a minimum of one singlet purchase per family, up to a max of 5. The cost for a family (5 or less) including insurance is: with one singlet: $110, with 2 singlets: $135, with 3 singlets: $155, with 4 singlets: $170, with 5 singlets: $180. All memberships are subject to committee approval, as outlined in the club constitution.
Name 1 *
Your answer
Date Of Birth 1 *
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Name 2 *
Your answer
Date Of Birth 2 *
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DD
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YYYY
Name 3 (if applicable)
Your answer
Date Of Birth 3 (if applicable)
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DD
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YYYY
Name 4 (if applicable)
Your answer
Date Of Birth 4 (if applicable)
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DD
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YYYY
Name 5 (if applicable)
Your answer
Date Of Birth 5 (if applicable)
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DD
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YYYY
Address *
Your answer
Phone number(s) *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Address *
Your answer
Emergency Contact Phone *
Your answer
Payment Method (in order of preference) *
Singlet Person 1 *
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Your answer
Singlet Person 2 (if applicable)
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Your answer
Singlet Person 3 (if applicable)
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Your answer
Singlet Person 4 (if applicable)
Your answer
Singlet Person 5 (if applicable)
Your answer
Electronic Signature *
Required
A copy of your responses will be emailed to the address you provided.
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