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Name in Full:

Address:

 

Phone (Home):

Phone (Mobile):

Email address:

Date of Birth:

Year

Occupation:

Gender:

Level of membership required:

Associate Membership

Full Membership

Already a member of a QLHF member group?

Group name:

Parents name:

Parents address:

Parents address:

Parental Consent:   I authorise my child to become an Associate Member of Mare Nostrvm.   I acknowledge that I am to be responsible for the care and well being of my own child at all times whilst they are participating in Mare Nostrvm activities.   I declare that all information supplied to Mare Nostrvm on this form to be true and correct.
Signature of Parent:
Date:

Acknowledgements (for applicants over the age of 18 years):   I understand that I will be a Probationary Member for six (5) months after which the Executive Committee will decide whether to upgrade my membership.   I declare that all information supplied to Mare Nostrvm on this form to be true and correct.

Applicants Signature:
Date:
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