Membership Form

Your Name (required)

If family membership, please give names of other family members:

Address (required)

Phone Numbers:

Home:

Work:

Cellphone:

Email Address:

Please give details below of a family member or friend who can be contacted in an emergency:

Name:

Contact Number:

HEALTH: Please give information of any medical condition, disability or special needs you have that the trip leader should know about (eg asthma, diabetes, allergies, joint replacement, contact lenses, medications) to ensure your safety while tramping.

Digital Signature:

By Ticking the box below and submitting this form you agree that all the above information is correct and this acceptance will constitute a digital signature