Individual Registration Form - 2014

Note: Generally when signing up as an individual, you will e

allo!ated to a larger team to assist and meet new people"
#R$ $%$N& INF'R()&I'N
1. Name : _______________________________________________
2. Gender : FEMALE | MALE
3. Age : _______________________
I(#'R&)N&: I* volunteer parti!ipant is under 1+ years o* age, !onsent
*rom parent,guardian must e granted-
4. Postal Address :__________________________________________________________
5. Email : ________________________________________________________________
Phone nm!er"s# $ell : ______________________ %ther : _____________________
&. Emergen'( $onta't Name : ________________________________________________
). Emergen'( $onta't Phone Nm!er : _________________________________________
*. Pre E+isting $onditions, ____________________________________________________
-. Are (o .illing to 'lean / an inland area, 0es1No
12. 3h( ha4e (o 'hosen to /arti'i/ate in $lean 5/ 6ar!ados 2214,
1. 7eam 6ilding &. 8o something good
2. $ommnit( /arti'i/ation ). 0o .ere told to
3. Parti'i/ate in 8ata $olle'tion *. 3ant to ha4e 9n
4. 0o ha4e an interest in the
en4ironment
-. %ther
5. 0o ha4e ado/ted (or area
Namel(,
__________________________
Please note:
The participant (signed below) agrees that the Future Centre Trust (local activity organisers)
and Clean Up The World Pty Ltd will not be liable for:
o ny sustained in!uries by any participant
o ny loss or da"age to property owned by# or in the possession of# the participant
o ny acts or o"issions# negligence or fault of any person participating in the
activity$
ny pre%e&isting conditions "ust be noted above which "ight affect your participation and
"ust be advised to your allocated 'ite 'upervisor prior to the start of the event so you can
be allocated appropriate tas(s$
)ue care "ust be ta(en with any tools issued by your allocated 'ite 'upervisor for the
event$ ny loss or da"age will be the responsibility of the user$
'igned: )ate:
#.$)/$ F)0 &1I/ F'R( &': 22434 320 2021 'R $()I. ) /5)NN$6 5'#7 &':
!leanuparados!ampaign8gmail-!om
This year we are encouraging clean-up teams to focus on inland areas which
may have litter or an illegal dumpsite. Teams with children are encouraged
however to register for beach locations.