SLSNR Club Instructor Registration Form Survey

To complete this registration you must be a qualified Surf Lifeguard Award or IRB Instructor

Or being intending to complete your instructors qualification this season

*
1. Please complete the following personal details:

Please complete the following personal details: First Name
Surname
Email Address
Mobile Phone Number
Home Phone Number

2. What is your preferred method of contact?

What is your preferred method of contact? Phone

Mobile

Email

*
3. Postal Address

Postal Address Street or PO Box Number
Suburb
City

*
4. Date of Birth

	DD		MM		YYYY
DOB:	Date of Birth DOB: Day	/	Month	/	Year

*
5. Are you a current member of Surf Life Saving New Zealand?

Are you a current member of Surf Life Saving New Zealand? Yes

No

*
6. Please identify your club

Please identify your club

*
7. What roles are you applying for?

What roles are you applying for? Surf Lifeguard Award Instructor

IRB Instructor

SLSNR Club Instructor Registration Form

1. Applicant Details

*1. Please complete the following personal details:

2. What is your preferred method of contact?

*3. Postal Address

*4. Date of Birth

*5. Are you a current member of Surf Life Saving New Zealand?