Car Club RMIT Inc

Officials' Registration

Please fill out this form to register as an official at the George Derrick Memorial Rally.

The event is Saturday 13th April, stages will take place in State Forests around Heyfield.

Questions marked in red are compulsory

Step 1: Contact Details

Title:		Home Phone:
Firstname:		Work Phone:
Surname:		Mobile:
Address:		Email:
Suburb:		Leave blank any field you do not wish to be contacted. However please provide at least one contact number.
State, Postcode
Occupation:		Vehicle:
Age:
Car Club Member:	Yes No If yes, which club?

Additional Information

Are you a CAMS Accredited Official?: Yes No If yes, License number
License Categories:
Please list any special skills (bobcat operator/chainsaw certificate/IT)?:
Do you hold a current First Aid Certificate? Yes No
Are you familiar with A to A timing? Yes No

Emergency Contact Information

Contact:	Name:
	Relationship:
	Phone:
Medical:	(a) Do you suffer from any pre-existing medical conditions we need to be aware of? Yes No If yes, please provide details (b) Are you presently on any medication we need to be aware of? Yes No If yes, please provide details (c) Do you suffer from any allergies we need to be aware of? Yes No If yes, please provide details

Step 2: Availability

1. Select who you were contacted by OR leave blank:	Other:
2. What role are you be interested in OR volunteering for?	Other:
Are there any other officials travelling with you?	Yes No If yes who?
How many friends will be travelling with you?	How many other vehicles?
Will you be bringing a mobile phone to the event?	Yes No If yes likely number?
Further information?

Car Club RMIT Inc. (CCRMIT) values your privacy. Personal Information that you provide on-line will be used by CCRMIT in conducting
the George Derrick Memorial Rally. CCRMIT will not disclose personal information to parties outside the event under any circumstances.