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Anniversary Form

Given Names

Surname

Date of Birth

Phone Number

Email Address

Postal Address

Address 1

City

ZIP / Postal Code

State / Province

Country

Responsible Person/Emergency Contact Name

First Name and Surname

Relationship

Phone Number

Are you affiliated with Trinity College in any ways?

Medical Update

Please list any updates to your current medical information that is different to the information previously provided to STARplex:

Please list any allergies you have (if applicable):

I give permission for first aid trained STARplex staff to provide the applicant with Ventolin if required in an emergency.

Agree

I give permission for photos/images of the applicant, taken as part of STARplex activities, to be used by STARplex for use in brochures, newsletters, internet or other promotional material.

Agree

I wish to receive information from STARplex about other programs, marketing and promotional material.

Yes

Confirmation

By submitting this form

You confirm you are at least 18 years old.
You agree to our terms, conditions and guidelines found on our website

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