subject_line
Southern Cross Annual 5 Day Poker Run Registration Form
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
*
Qld
WA
NT
ACT
VIC
SA
NZ
TAS
-
-
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
Calculate
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
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