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HAWKESBURY DISTRICT SENIOR CITIZENS CENTRE

114 MARCH STREET RICHMOND NSW 2753

PHONE/FAX: 45 782072

APPLICATION FOR MEMBERSHIP

DATE: ..........................

SURNAME: ...................................................

CHRISTIAN NAME : . .....................................

ADDRESS: ....................................................

................................... POSTCODE: ...............

PHONE NO : ..........................

RELIGION (OPTIONAL ): ................................

DATE OF BIRTH : ........................

NAME OF FAMILY DOCTOR: ..............................

ADDRESS : .....................................................

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PHONE NO : ........................

LIST OF MEDICATION: MEDICAL PROBLEMS:

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CONTACT PERSON IN CASE OF ACCIDENT: .........

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ADDRESS: . .....................................................

PHONE - HOME :................WORK......................

SIGNATURE: . .................................................