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Registration
Registration form:
Parents/Guardians must sign form below and circle Yes or No to each item -
I .................................................................
being the Parent/Guardian of:
Student name.......................................................
Postal Adress......................................................
................................................................................
School...........................Grade........
Phone number (h).........................................
(m)..............................................................
Student email....................................................
1. Give consent for him/her to attend the ..........................Fusion Australia Breakout. Yes / No
2. Agree to pay $................ to ensure a seat. Yes / No
3.Give consent for Fusion to take photos and video footage of him/ her for promotional purposes. Yes / No
4. I hereby release Fusion, its servants or its agents for any liability arising to him/her through accidents or injury and authorise Fusion to arrange necessary medical treatment.
My Medicare number is................................................ .Yes / No
5.Special Dietary requirments (e.g. vegetarian) ......................................................
6. I will get on the Bus at...................................................................
7.Special medical details
............................................................................................................................................................................................................
............................................................................................................................................................................................................
Signature....................................... Date................
..........................................................................................................................................................................................................
To register you must send form and payment by email, fax, or post to-
By email:
(Email permission not yet available)
Delivered to:
98 Beach Rd Kingston
(On the right hand side heading towards Kingston Beach. Past main traffic lights 2 blocks down from St Clemments Church behind Raine& Horne Real Estate)
By mail:
Completed form and payment to:
Breakouts Coordinator
Fusion Australia
Po Box 264 Kingston 7051
Ph 03 6229 1939
Fax 03 6229 8591
Registrations and Payment must be in by the Wednesday before the day to ensure a seat on the bus. Strictly limited seats, so get in early.
Fusion
Big Night Out
Send E-Mail to: chrisd@fusion.com.au
Copyright © 2005 . All Rights Reserved