1. Details

 
 11% of survey complete.
Thank you for your interest in Seniors Games, we are really excited to hear from you!

Get ready to fill your Wednesday's meeting new people, learning skills, getting active and most importantly having fun! 

We recommend wearing clothes and shoes you feel comfortable in and can move around easily. 


If you have any questions, please don't hesitate to contact J-Mara McDonald on (8459 0932) or jmara.mcdonald@vahs.org.au
Alternatively contact the Preventative Health unit on 94033300
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We can't wait to get started!

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1. Full Name: (Required.)

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2. Gender: (Required.)

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3. Are you: (Required.)

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4. Date of Birth (DD/MM/YYYY): (Required.)

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5. Current Age: (Required.)

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6. What is your street address? (Required.)

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7. Suburb/City: (Required.)

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8. Postcode: (Required.)

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9. Mobile Number: (Required.)

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10. Email address: (Required.)

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11. Emergency contact name: (Required.)

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12. Emergency contact number: (Required.)

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13. Emergency contact's relationship to you: (Required.)

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14. How did you hear about this program? (Required.)

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