Step Out & Get Active 2012

Booking Request Form

First Name: *

Surname: *

Gender: *

Male

Female

Age Bracket: *

Section A: Contact Details

Email: *

Repeat Email: *

Postal Address: *

Suburb: *

State: *

Postcode: *

Phone: *

Mobile:

In case of Emergency Contact Name: *

Emergency Contact Telephone: *

Are you registering with a partner, friend(s) or group? If yes, please indicate a Group Name.
This Group Name needs to be stated on all group members Booking Request Forms.

Section B: Session Request

Please indicate in the boxes below which session you would like to participate in, in order of preference 1 to 3, 1 being most desirable.
Please visit http://www.activeseniorsnsw.com.au/activities.php for session descriptions. You will be notified of which session you are confirmed in at the beginning of March.

	Session 1: All Day Coast Walk (HARD) Optional (EASY)
	Session 2: Live Well Talk & Circuits (EASY) Half Day Coast Walk (MOD.) Optional (EASY)
	Session 3: Aboriginal Culture Walk (EASY) Zumba (MOD.) Landscape Art Class (EASY)
	Session 4: Bike Ride (HARD) Live Well Talk & Circuits (EASY) Photography Lesson (EASY)
	Session 5: Guided Bush Walk (MOD.) Live Well Talk & Circuits (EASY) Water Sports (MOD.) Zumba (MOD.)
	Session 6: Tai Chi (EASY) Water Sports (MOD.) Aboriginal Culture Walk (EASY)
	Session 7: Kayak (MOD.) Zumba (MOD.) Photography Lesson (EASY) Optional (EASY)
	Session 8: Zumba (MOD.) Photography Lesson (EASY) Guided Bush Walk (EASY)
	Session 9: Guided Bush Walk (EASY) Tai Chi (EASY) Live Well Talk & Circuits (EASY)
	Session 10: Photography Lesson (EASY) Tai Chi (EASY) Landscape Art Class (EASY) Watersports (MOD.)

Any comments?

Section C: Additional Information

How do you intend to travel to the Royal National Park? *

	Train to Sutherland Station then catch the free shuttle bus to Audley
	Private Vehicle
	Other, please specify

Lunch is not included. We recommend you bring your own packed lunch, or you will be able to purchase lunch from the Weir Café at retail price.
Please choose *

	I will be purchasing my lunch at the Weir Café
	I will be bringing my own packed lunch

Do you have any food allergies? *

	Yes	What Allergy?
	No

How did you hear about Active Seniors?: *

Section D: Participant Waiver

Please indicate your acceptance to the participant waiver below.

I acknowledge that I participate in the Event at my own risk. I will take all reasonable measures to protect myself from the risks of participation. To the best of my knowledge, I am not suffering from any condition which would prevent and/or render me unfit to participate in this event. I will additionally permit the free use of my name and pictures in broadcast, telecast and print. I agree to abide by the event rules and any other instructions as indicated by the organisers. I acknowledge that the organiser of the event reserves the right to reject my entry form and/or exclude me from participating in the event in its absolute discretion. I agree to receive and pay for medical treatment including transport by ambulance, which is considered by the organisers to be advisable or which is provided to me at the request or direction of the organisers before, during or after the event. I, being the participant, have read and agree to these terms and conditions and give my permission for my person information to be to be entered into a database to have my Booking Request processed and agree to the condition that my personal information will not be disclosed to any third party directly involved with this event. This waiver, release and discharge applies to all persons corporations and bodies involved or otherwise engaged in promoting or staging the event and the agents, representatives and officers of them. This waiver, release and discharge operates whether or not the loss injury or damage is attributable to negligence or other act of omission of any one or more of those parties.

The purpose of collecting your entry information is to enable the owners of the event (Event & Sports Projects Australia Pty Ltd) to process your application as a participant of 'Step Out & Get Active'. Your personal information may be disclosed to 'Step Out & Get Active' event related partners and sponsors (Ageing Disability and Home Care - ADHC).

Waiver: *

I ACCEPT

I DO NOT ACCEPT

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Please Note

We endeavour to place every participant into their first preference, however as there are limited spaces available per session this is not possible in all cases.