Gallop South Membership Form


Season Pass Holder Details Form

Please complete this form and return with your subscription fee to ensure our records are kept up-to-date.

Title  Mr / Mrs / Ms / Miss / Dr / Other                                                                                    

First Name                                                                                                                                      

Last Name                                                                                                                                       

Address                                                                                                                                           

                                                                                                                                                         

                                                                                                                                                         

City                                                                                                                                                 

Postcode                                                    

Email                                                                                                                                              

Phone                                                                                                                                             

Mobile                                                                                                                                           

 

Please circle ONE club for which you would like voting rights:

Beaumont RC               Central Otago RC        Gore RC                      Kurow JC
Oamaru JC                    Otago RC                      Riverton RC                Southland RC
Tapanui RC                   Waikouaiti RC              Wairio JC                    Winton JC
                                       Wyndham RC

Signature                                                                      Date