Medical Team Registration 2016 Please ensure you have read the Disclaimer Exclusion of Liability Release and Assumption of Risk before completing this form. Surname*Name*Date of Birth*Phone*Email* Address*Address Line 2City / Town*State*Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaPostcode*CAMS Officials Licence NumberLicence GradingSpecial Dietary Requirements* None Vegetarian Vegan Gluten Free Lactose Free Diabetic Egg Free No Pork Other Details of Dietary Requirements Do you require a guest pass?*YesNoEmergency Contact Name*Emergency Contact Number*Pre Existing Medical Conditions Availability* Friday 17 June Saturday 18 June Sunday 19 June Disclaimer*I confirm I have read and understood the Volunteer Officials Terms and Conditions and the 2016 Disclaimer and Exclusion of Liability I confirm