LTM- Form | Mallee Arts coLab

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PARTICIPANT INFORMATION + CONSENT

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First name

Last name

Email

Phone

Birthday

Day

Month

Year

*Do you require transport to and from the Lake Culluleraine Festival?

Yes

No

*If 'YES' pleave provide your address.

Please provide the name, relationships & contact details of your emergency contact.

Please list any medical conditions, allergies, accessibility needs, or dietary requirements that organisers should be aware of:

Do you require a camp site or a bed in the dormitory:

I consent to photographs and media being taken and used as described above.

106-108 Pine Ave
Mildura
VIC 3500
hello@malleeartscolab.org

CONTACT US

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HOME
WHAT'S ON
- Upcoming Programs & Events
- Past Programs & Events
OUR PEOPLE
MALLEE CREATIVES
PARTNERS

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