Halberg New Participant Form

Participant Details

Salutation

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First name

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Last Name

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Email (if applicable)

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Home Phone

Mobile Phone

Date of Birth

Gender

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Mailing Street

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Mailing Suburb

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Mailing City

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Mailing Postcode

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School (if applicable)

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Current sports/recreational activities you are involved in? (ie. cycling, swimming etc)

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Current sports clubs you attend?

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Sports and recreational activities of interest

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Region

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Parent/Caregiver Details

Salutation

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First name

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Last Name

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Phone Number

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Mailing Street

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Mailing Suburb

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Mailing City

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Mailing Postcode

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Email (if applicable)

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Invalid email.

Relationship to participant

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Halberg information interested in receiving

Halberg NET Inclusion Training Course

Halberg Games

Activity Fund

Regional Sports Events

Parafed Information

Paralympic NZ Information

Other

Do you give permission to receive information from Halberg partners about disability sport and recreation activities?

Do you want to receive Halberg newsletters and information?

Thank you for your interest, the Halberg Foundation looks forward to supporting you. Please don’t hesitate to contact your local Adviser for more information. Click here for contacts.

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