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 *

Post Code *

Email Address *

Phone Number *

Meals, long sleeve and sizes 6XL and 7XL must be ordered and paid for by 31 July. If you order after this date we cannot guarantee you a shirt in your size.

Class *

Red Class: includes Dinners & B'fasts, T-shirt, Badge & Camping, Poker Hand- $400

Blue Class: includes Dinners, T-shirt, Badge & Camping, Poker Hand- $320

Green Class: includes Breakfasts, T-shirt, Badge & Camping, Poker Hand- $270

White Class: includes T-shirt, Badge & Camping, Poker Hand- $170

Long Sleeve Shirt *

Yes-$10

Payment: Direct Debit Only. Acc Name: Southern Cross Association (FTC) Inc.
Bank: Bendigo BSB: 633000 Acc No.: 128514205 Your Ref: Initial.SurnamePR24

Payment Options *

Direct Debit

Date of Deposit * +

Current Total:

$0.00

Are you able to help with cards, meal sheets etc at the campsites?

Yes