Enrolment Form

Royal Life Saving Society Qld
PO Box 1093
Capalaba DC QLD 4157
Ph: 07 3823 2823 Fax: 07 3823 2423

Title: Mr \| Mrs \| Miss \| Ms \| Dr	Last Name:	First Name :
(These names will be used on Certificate)
Address (1)
Address (2)
Suburb: Postcode: State:
Phone Number: Work Number: Mobile Number:
Email:
Amount:
Statement of Attainment
Re-accreditation (Please insert Date of Original Statement of Attainment)
Course Code:
Pre-requisites (please ticket appropriate box) Not Applicable Oxygen Equipment - Pre-requisite: First Aid Certificate Pool Lifeguard Full - Pre-requisite: First Aid Certificate & RLSSA Bronze Medallion Certificate Pool Lifeguard Update - Pre-requisite: First Aid Certificate & expiring RLSSA Pool Lifeguard Certificate
Choose one Payment Option : 1. Credit Card 2. Invoice 3. Money Order 4. Cheque
1. Credit Card: Name on card:
Card Number: Expiry:
3. Invoice to:
Business Name:
Address (1)
Address (2) Suburb: Postcode:
4 & 5 Payable to Royal Life Saving Society Queensland
I have read and accept the conditions of enrolment. Signed:
(Please sign after you print. Fax and postal address details are on the top of the page)