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Name
in Full: |
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Address: |
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Phone
(Home): |
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Phone (Mobile): |
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Email address: |
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Date of
Birth: |
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Occupation: |
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Gender: |
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Level of membership required: |
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Already a member of a
QLHF member group? |
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Group
name: |
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Parents
name: |
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Parents
address: |
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Parents
address: |
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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. |
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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. |
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