Selected Course: OutThere - After School Program Sessions: Wednesday 5th February, 4:15 pm - 6:15 pm Wednesday 12th February, 4:15 pm - 6:15 pm Wednesday 19th February, 4:15 pm - 6:15 pm Wednesday 26th February, 4:15 pm - 6:15 pm Wednesday 5th March, 4:15 pm - 6:15 pm Wednesday 12th March, 4:15 pm - 6:15 pm Wednesday 19th March, 4:15 pm - 6:15 pm Wednesday 26th March, 4:15 pm - 6:15 pm Price: $450.00 SYC Member Price: $430.00 Participant Details First Name: * Last Name: * Date of Birth: dd01020304050607080910111213141516171819202122232425262728293031mmJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberyyyy2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901 Gender Female Male Other (PH) Home: (PH) Mobile: * Email Address: * Street Address: * Suburb / Town: * Postcode: * State: ACT New South Wales Northern Territory Outside Australia Queensland South Australia Tasmania Victoria Western Australia Referrer: -- Australian Sailing Course Finder Bayside Directory Friend/Relative Internet Other Previous Participant School Group School Newsletter SYC Member SYC Website Australian Sailing Number: Click here to search for your AS number Medical Details Emergency Contact: Emergency Contact (PH): Do you have or had any of the following conditions: Asthma Hepatitis B Heart murmurs Epilepsy Diabetes Hernia Hepatitis A Heart Problems Other Do you have any allergies? No Yes: Do you take regular medication? No Yes: Have you had a serious injury in the last five years? No Yes: Are you a SYC member? Surname Membership Number You will require this to be eligible for the Member discount. Do you have a Voucher? If you have a SYCBA voucher, please enter its unique code. In case the voucher does not cover the full cost of the course, please make sure you have selected one of the payment methods below to cover the remaining amount. Payment Type: MasterCard Visa AMEX Please note that the facility to charge your membership account is only available for Senior, Associate and Intermediate members. For all other membership types and non members, please pay via credit card.
