Event Access Form

Note: only members listed below will receive Personal Accident Coverage for the specified event. A claim form should be completed and submitted as soon as you become aware that you will be making a claim and within 30 days of the injury occurring. You do not have to wait until after you have completed treatment for your injury. Please note that any treatment rendered necessary by injury must be completed within 12 calendar months from the date of such injury occurring for expenses to be covered. If you need more time, please notify events@austkd.com.au.

Head Instructor Name*

First NameLast Name

Club Name*

Event Name*

Organising Club Name*

Event Location*

Street Address

Street Address Line 2

CityState

Post Code

Total Number of Club Members participating in the event*

Please enter the full names (first name and last name) of each participating member below, separated by a comma - example (John Smith, John Doe). *