Intersection Collection Registration Form

Rabbit Run-Away Orphanage - Winston's Challenge Registration Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Number*
E-mail*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Relationship*
Please provide ONE form of ID*

Drivers LicencePassport NumberOther
ID Number*
Drivers Licence, Passport No or other
Member or Account Number
Superannuation Fund Name
Superannuation Fund Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Superannuation Fund Phone Number

Area CodePhone Number
Declaration

I declare all information on this form to be true and correct, and that I am over the age of sixteen years. I have read and understood the “Intersection Collector Conditions”, as well as the “Intersection Permit Conditions” set out by police and council and agree to abide by them at all times. I also agree to represent the charity in a professional manner.

By clicking the Submit button, I agree to the terms stated above.
Thank you for taking the time to fill this form out.

The Intersection Collection Coordinator will be in touch with you within 7 days.

(PLEASE CHECK YOUR 'JUNK-EMAIL' FOLDER FOR A REPLY)
Should be Empty:

Rabbit Run-Away Orphanage - Winston's Challenge Registration Form