Course Booking Form Course Details OutThere Sailing. Course 6: 11.30-2pm (12-14 yrs) Cost: $200.00 $250.00 non-members Sessions Wednesday 23rd January, 11:30 am – 2:00 pm Membership Details Are you a club member? Username (Membership Number) Password * You will require this to be eligible for member pricing. Participant Details Name: First name Last name Date of birth: Gender: Female Male Undefined Phone: Home Work Mobile Email address: Street address: Suburb / Town: Postcode: State: ACT New South Wales Northern Territory Outside Australia Queensland South Australia Tasmania Undefined Victoria Western Australia AS member number: Click here to search for your AS Number Emergency contact: Name Phone number Medical Details Blood group: Unknown O Positive O Negative A Positive A Negative B Positive B Negative AB Positive AB Negative Do you have (or ever had) any of the following conditions? Asthma Hepatitis B Heart murmurs Epilepsy Diabetes Hernia Hepatitis A Heart Problems Other: Do you have any allergies? No Yes: Do you take regular medication? No Yes: Have you had a serious injury in the last five years? No Yes: Notes Payment Method Are you paying with a voucher? If you have a voucher, please enter its unique code. In case the voucher does not cover the full cost of the course, please make sure you have selected one of the payment methods below to cover the remaining amount. Pay using: MasterCard Visa Review Details & Confirm Payment