Ski-nZ 'Max' Ground Crew Form 2018

This is an electronic form to be completed by each ‘Ground Crew’ person attending. Please fill in all questions then submit by clicking on ‘Done’ at the end of the form.

Each 'Ground Crew' person is required to pay a provisions levy (amount TBA) and will include: Most meals, entertainment and merchandise. The provisions levy will be set to cover actual costs & is payable before 16th February 2018)

Ground crew entries received after 9th February 2018 will incur a $100 'late' donation fee.

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* 1. Personal Details

Title

First Name

Last Name

Preferred Name/Nickname

Company

Occupation

Mobile

Home Phone

Work Phone

Fax

Address (Work / Home?)

Suburb

Post Code

City

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* 2. Men's Tshirt size? (The cost is covered by the provisions levy.)

2XL

3XL

4XL

5XL

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* 3. Ladies Tshirt size? (The cost is covered by the provisions levy.)

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* 4. Long sleeve event rash shirt required at $65 extra?(Orders for these required by 1st December 2017)

Yes

If yes, please state size:

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* 5. Who are you ground crew for?

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* 6. PLEASE NOTE: Your drivers licence must be shown at Registration

Driver’s Licence Number

Driver’s Licence Expiry

Driver’s Licence Class

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* 7. Medical Information (Strictly Confidential)

D.O.B

Next of Kin

NOK Phone

NOK Alt Phone

Allergies/Dietary Requirements (eg. vegetarian)

Past Medical History

Current Medical Condition/Medication

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* 8. Please deduct my provisions levy fee on 16th February 2018 (Amount to be confirmed but not to exceed $550 for the event)

Credit Card Type (e.g. Visa)

Card Number

Expiry

Cardholder's Name

Date

Please email a recent head & shoulders photo by email to Mel on admin@melanoma.org.nz before 31st January 2018.
This will be used for ID purposes.