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Member Details

Title

First Name*

Last Name*

Date Of Birth*

Sex

Email*

Alternate Email1

Alternate Email2

Residential Address

Address

Suburb

Country

State

Post Code

Home Phone

Mobile*

Mailing Address

Address*

Suburb*

Country

State*

Post Code*

Work Phone Ext.

Fax No.

Other information

EA Member Number

Affiliate members MUST supply their EA number

If joining the Family membership the Parent/Guardian must supply their own details here

Note: The Family Membership Fee includes One Parent/Guardian & up to Two Children. Any more children are extra and will be automatically charged

All members must help with at least two activities. This is a condition of membership. *

I agree to my childs photo being used for NAGs benefit. *

Yes

I agree to abide by the code of conduct listed below *

Code of Conduct

Email address is already assigned to a member,
please use an alternative email address.

You appear to be an existing member.
Do you want to renew your membership?

Primary Member must be an Adult/18+. Children/under 18 memberships can be added on the next page.

Aged pension membership is for members over 65 years.
Please choose another membership type or correct your date of birth.

EA number does not match member name.

To be eligible for this membership, a doctors certificate/para classification/RDA associate membership must be provided to the club to receive a code to apply for this membership type. Please type code in below.

Northcoast Active-Riders Group Inc (NAGs)

Member Registration

Member Details

Residential Address

Mailing Address

Other information

Code of Conduct