Duke of Ed- Expression of Interest
By registering your details with Queensland Rugby, you consent to our organisation contacting you via these details and may send your contact information to our referee ready programme coordinators or local clubs for their records. If you wish for your details not to be forwarded to these parties, please advise Queensland Rugby representatives when we reply to your registration.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently attend School ?
Please Select
Yes
No
If yes, what School do you attend?
Do you currently attend a University?
Please Select
Yes
No
If Yes, what unversity do you attend?
We recognise that some of our members are completing The Duke of Edinburgh's International Award and may be using this sport and club membership to complete one or more Sections of their Bronze, Silver or Gold Level. Are you using this sport for your Duke of Edinburgh's International Award?
*
Yes
No
Duke of Ed Level you are completing
*
Gold
Sliver
Bronze
Interest but not yet registered
Submit
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