PLEASE READ BEFORE COMPLETING THIS FORM

This form should be completed by an Adult on behalf of the participant.

To complete this form please ensure you have -

- if you have one, the name of your sponsoring Rotary / Rotaract Club and the name and contact details of the person at the club who has agreed to the sponsorship (usually the Youth Director).
- your medical information, including medicare card number and private health insurance (if applicable)

The form will take approximately 10-15 minutes to complete and must be completed and submitted in one session - you cannot save your progress and return later.

CONFIDENTIALITY STATEMENT

The Rotary District 9640 Youth Committee is committed to maintaining all personal information provided by the Applicant and their families in accordance with the Australian Privacy Principles.  Information collected will be stored in a confidential manner and access granted only as outlined in the Applicant Declaration section.  Procedures will be implemented to ensure that this information is protected and secure and remains confidential.

QUERIES

If you have any queries about completing this form, please contact rypen@rotary9640.org