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Expression of Interest Form
Douglas Park Wilton Physical Culture Club 2026
Form Submission Date
*
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Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
CONTACT INFORMATION
Parent/Guardian
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Mobile Phone Number
*
Enter valid mobile number. Will also be used to receive text msgs.
Format: 0000 000 000.
Email Address
*
CHILD INFORMATION
Child's Name #1
*
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Child's Name #2
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
EMERGENCY CONTACT
Emergency Contact:
First Name
Last Name
Emergency Contact Number
Format: 0000 000 000.
Which location will you be attending
Monday's at Douglas Park Community Hall
Wednesday at Wilton Anglican Church Hall
Both
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How did you hear about us?:
Enter any question or additional information pertaining to the contents and or the purpose of this form., in 50 words or less.
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Facebook and Instagram - Douglas Park Wilton Physical Culture Club
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