26/27 Gold Coast Age Manger Workshop
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Non-Binary
If Non-binary: Please specify what pronouns you would like used
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Branch
*
Please Select
South Coast
Point Danger
South Coast Clubs
*
Please Select
Point Lookout
Coochiemudlo
Southport
Surfers Paradise
Northcliffe
Broadbeach
Kurrawa
Mermaid Beach
Nobby's Beach
Miami Beach
North Burleigh
Burleigh Heads Mowbray Park
Point Danger Clubs
*
Please Select
Tallebudgera
Pacific
Palm Beach
Currumbin
Tugan
Bilinga
North Kirra
Kirra
Coolangatta
TH&C
Rainbow Bay
Role
*
Please note: Members are only required to attend one of the workshop dates. Two workshops have been scheduled due to the size of the Gold Coast region and to provide greater accessibility for members. The same content will be delivered at both workshops, so there is no requirement to attend both days. Workshop locations and dates are outlined below
*
12th September 2026 South Coast Branch Building
13th September 2026 Pacific SLSC Function Room
Either Day works for me
Medical and Dietary Details
Morning Tea will be provided on the day
Do you have any Dietary Requirements?
*
Please Select
Yes
No
Please provide further details on dietary requirement
*
Do you have any of the following medical concerns:
*
No
Skin Conditions
Epilsepsy/Fits/Blackouts
Chronic Illness
Diagnosed Mental Illness
Diabetes
Asthma
Allergies
Accessibility requirements
Other
Please provide further details on medical issue
*
Do you take any medication that we should be aware of?
*
Please Select
Yes
No
Please list these medications and when they are required.
*
Do you require assistance in taking this medication or is it self-managed?
*
Please Select
Self Managed
Require Assistance
Signature
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Should be Empty: