ConventionRego

Lions District 201Q4 2023 Convention Registration Form
Where: Blackbutt Showgrounds, 23 Bowman Road, Blackbutt, 4314

When: Friday 27th October 2022 to Sunday 29th October 2023

Registrations: Friday 12-6pm, Saturday 7-8am

SUBMIT this form by no later than 31st August 2023

Enquiries to convention.q4@lions.org.au

Friday Night Dinner – "Dress Casual"

Saturday Night Dinner - "Dress your Best Bachelor & Spinster Ball’’
District*
eg 201Q4
Club Name*
eg Blackbutt Benarkin
Club Number*
eg 77807
Title*
First Name*
Last Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Home Number
Please enter a valid Home Number
Primary Contact Mobile Number*
Please enter a valid Mobile Number.
Primary Contact E-mail*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Mobile Number*
Please enter a valid Mobile Number.
First Convention

YesNo
Rego of Interest Completed

YesNo
Food Options

VegetarianDairy FreeGluten FreeVeganOther
Saturday Lunch Choice*

Pie BeefPie ChickenPie VealWrap Salad

Person 2

Person 3
Convention Costs - Enter the quantities against each item to calculate total cost
Item1
Cost1
Qty1*
Value1
Item2
Burger & Chips
Cost2
Qty2*
Value2
Item3
Cost3
Qty3*
Value3
Item4
Blackbutt Bakery Pie and Salad
Cost4
Qty4*
Value4
Item5
Cost5
Qty5*
Value5
Item6
3 Course Feast
Cost6
Qty6*
Value6
Item7
Bacon & Egg Burger Fruit
Cost7
Qty7*
Value7
Item8
Cost8
Qty8*
Value8
Item9
Wrap for takeaway
Cost9
Qty9*
Value9
Item10
Cost10
Qty10*
Value10
Total Value
Total
EFT Payments to:

Lions Club of Blackbutt Benarkin BSB 633 000 Acc 198761207

Reference = Full Name Primary Contact

Cheques made out to:

Blackbutt Benarkin Lions Club Convention

PO Box 70, Blackbutt, 4314, QLD
Accomodation Options

Caravan Camper Trailer Camping Options

Blackbutt Showgrounds PH 0437 665 199 (Terry) $10pp
Blackbutt Free Camp (600m) D'Agular Hway on left towards Yarraman
Benarkin Free Camp (5km) D'agular Hway turn left towards Kilcoy then on right

Motel,Hotel and Cabin Acccom

Radnor Hotel Blackbutt (9 rooms) (200m) PH 4163 0203 $100-120
Blackbutt Motel (9 rooms) (250m) PH 4163 0500 $110-130
Yarraman Caravan Park and Cabins (12 Cabins) (15km) PH 4163 8185 $110-140
Yarraman Gardens Motel (3 rooms) (15km) PH 4163 8144 $110-130
Copper Country Motor Inn Nanango (11 rooms) (36km) PH 4163 1011 $150-160
Fitzroy Motel Nanango (10 rooms) (36km) PH 4163 1100 $135-145
Nanango Star Motel (8 rooms) (36km) PH 4163 1666 $110-125
Camp Duckadang Dormitory Acc 8 per room (43km) PH 5408 5424 $25
Camp Duckadang 2 bed Ruby House (43km) PH 5408 5424 $150
Date Submitted

MonthDayYear
Date
Hour MinutesAM/PM Option
Payment Received Date

MonthDayYear
Date
Should be Empty:

Lions District 201Q4 2023 Convention Registration Form