Poker Run Registration Form 1 August

Please DO NOT fill out this form if you are paying by cheque/money order or cash.

First Name *

Last Name *

Date * +

Street Address *

City *

State *

Post Code *

Email Address *

Phone Number *

Registrations after 1st August will default to WHITE CLASS, (no meals) and a $10 surcharge will apply for late resgistration.
Please note, you will not be guaranteed a shirt, and no discounts will be given if there are no shirts available.

Class *

White Class: includes Badge & Camping, Poker Hand. Shirt not guaranteed - $180

Shirt Size: *

S-Unavailable

M-Unavailable

L

XL

2XL

3XL

4XL-Unavailable

Payment: Direct Deposit Only. Acc Name: Southern Cross Association (FTC) Inc.
Bank: Bendigo BSB: 633000 Acc No.: 128514205 Your Ref: Surname

Payment Options *

Direct Deposit

Date of Deposit * +

Current Total:

$0.00

Blue Card (optional) This section is optional. Note: Blue cards are required when giving rides or Marshalling, as per our Duty of Care Procedures.

Blue Card Holder

Willing to give rides at camping grounds / schools

Willing to be a Marshal for rides

Willing to help with meals, bar, activities etc?

Yes

Southern Cross Annual 5 Day Poker Run Registration Form