AC Non Member Triallist Register Summary QC

							                  Australian Canoeing Triallists Insurance - Club Non Member Application Form

 Trial Canoeist Processing - As the insurance policy requires AC to be notified within seven days of the activity of any trial canoeist, please
 complete participant details and either fax, email or mail to Queensland Canoeing:                                               Queensland
                  Canoeing, PO Box 7007, Upper Mt Gravatt, QLD 4122 Email: qld@canoe.org.au . Fax : (07) 3349 1911
                                    Trial Canoeist Event Fees:    Senior $5.50     Junior/Pensioner $3.30
Club                                                                   Date Forwarded to QC:     _____________
Contact Person:                                                        Event Name:     _____________________________________
E-mail:                                                                Date of Event:  ____________
                                                                       No of Seniors:     _____ No of Juniors:    _____


                                                                                          Post Code
Name                            Address                                City                           Date of Birth         Senior/Junior