Ithaca - Caloundra City Life Saving Club Inc




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Grey Medallion Enquiry / Registration

Please complete the below form to enquire or register to attend the next Grey Medallion course.

Click here to find out more information about the Grey Medallion.

The next Grey Medallion course is scheduled for:

Saturday 26 August 2017 and Sunday 27 August 2017
Our original course is now oversubscribed, we are planning a second course for
Saturday 21 & Sunday 22 October 2017

at BreakFree Grand Pacific, 100 Bulcock Street, Caloundra
9am to 4pm

Please complete one form for each person

Please enter your name:
Title:
First name:
Last name:


Compulsory field

Please enter your email address:
Compulsory field

Please let us know you address:

Please enter your phone number:
Compulsory field

Are you enquiring or registering?

 Registering (I am attending)

Enquiring (I may attend)

Neither, please contact me about the course

What is your gender ?

 Male

Female

I do not wish to specify

If an emergency occurs, who should we contact:

 Emergency Contact Name:


Contact Telephone Number:

Please let us know about any disabilities you have, or special arrangements we may need to make for you:

Please enter any messages or questions:
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© Ithaca - Caloundra City Life Saving Club Inc ABN 69 400 598 562
29 The Esplanade, Bulcock Beach
PO Box 1648, Caloundra Qld 4551
email enquiries@CaloundraCity.org.au
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