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GOLD membership

Your details

In order to join the GOLD program please complete this form. Once completed you name will be added to the email database where you will receive regular emails updating you on programs and advertising registration for upcoming activities.

NameRequired

AddressRequired

Contact numberRequired

Email addressRequired

Your date of birthRequired

Please list any medical conditionsRequired

Emergency contact nameRequired

Emergency contact phone number (An alternative phone number)Required

Emergency contact relationship to youRequired

Do you require a mobility aid? If so please specify.

Toggle help Walking stick/wheelchair/walker etc

Do you consent to your photo being used for marketing purposes?Required

Yes