AFRF FRESHER APPLICATION

Australian First Responder Foundation First Responder Emergency Services Health Education Retreat (FRESHER) Registration Form

All information collected is considered confidential and used by the Australian First Responder Foundation only for Retreat coordination and evaluation.
Particpant Information
Date of Retreat*
Name*

First NameLast Name
Birth Date

MonthDayYear
Mobile Phone *

Country Code Number
Home Number

Area CodePhone Number
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
Which describes your role

Career Emergency First ResponderVolunteer Emergency First Responder
Years of service as an Emergency First Responder
Which service do you give time to

State Emergency ServiceAmbulance ServiceRural Fire ServicePolice ServiceSt John AmbulanceFire ServiceSurf Life Saving AustraliaMarine RescueOther
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
I agree to the following:
1. I agree to abide by all AFRF policies and procedures, and to comply with all reasonable directions of AFRF officers, employees, agents, representatives, personnel and volunteers.
2. I agree to abide by all policies and procedures of the venue at which the FRESHER retreat is being conducted, and to comply with all reasonable directions of the venue’s officers, employees, agents, representatives, personnel and volunteers.
3. I agree not to use drugs or alcohol (other than prescribed drugs) for the course of the FRESHER retreat and that unauthorised use may result in my ejection from the FRESHER retreat.
4. I warrant that the FRESHER retreat delivered without charge in exchange for my promises herein.
5. I warrant that the information provided in this form is true, accurate, and complete, and that AFRF is relying on it as to its truth, accuracy, and completeness.
6. I warrant that I have made full disclosure of all conditions, concerns, or circumstances which could cause me or any other person any injury or loss or damage.
7. I fully and unconditionally release and indemnify AFRF from any liability arising from a breach of these warranties.
Medication Allergies or Other Allergic Reactions:
Dietary Needs/Restrictions:
Are there any medical, psychological or mental health concerns that you are currently seeking treatment for? Please provide brief information on these:
Activity Restrictions:
Medication Taken Regularly:
Tell us why you would like to attend an FRESHER weekend
Please use this space to ask or voice any concerns you might have about the weekend.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature

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Payment: There is no cost to accepted participants at AFRF FRESHER weekends. You may choose to make a donation while at the retreat or via our PayPal link as you submit this form but you are not required to.
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AUDAll donations are tax deductible
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Australian First Responder Foundation First Responder Emergency Services Health Education Retreat (FRESHER) Registration Form

Payment: There is no cost to accepted participants at AFRF FRESHER weekends. You may choose to make a donation while at the retreat or via our PayPal link as you submit this form but you are not required to.