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Member Details

Title

First Name*

Last Name*

Date Of Birth*

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Email*

Alternate Email1

Alternate Email2

Residential Address

Address*

City/ Town*

Country

Province*

Postal Code*

Home Phone

Mobile*

Mailing Address

Address

City/ Town

Country

Province

Postal Code

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Fax No.

Other information

EA/IQ Membership Number (optional):

MEDICAL CONDITIONS

Please provide information relevant to any potential medical issue that may arrive whilst participating in BCDG activities, including any considerations for First Aid Officers and Medical Personnel in the event of a fall or other accident.

Allergies: *

Allergy Treatments: *

Medical Conditions: *

Relevant Medication: (eg. Epilepsy Medication, Blood Pressure Medication etc) *

Relevant Information for the First Aid Officer and Medical Staff *

MEDIA CONSENT

Permission for the taking of photos and video footage for circulation through media outlets, including but not exclusive to: BCDG Club Newsletters, Facebook, Website and general notices, Publication in newsletters, Viewing on other media outlets

Media Consent *

Yes

Email address is already assigned to a member,
please use an alternative email address.

You appear to be an existing member.
Do you want to renew your membership?

Primary member must be over 18 years of age.

Aged pension membership is for members over 65 years.
Please choose another membership type or correct your date of birth.

EA number does not match member name.

To be eligible for this membership, a doctors certificate/para classification/RDA associate membership must be provided to the club to receive a code to apply for this membership type. Please type code in below.

Bundaberg Country Dressage Group Inc.

Member Registration

Member Details

Residential Address

Mailing Address

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