Goldfields CommonHealth Games for Seniors 2025

Team Name*

Number of team members (maximum 8 members)*

Number of support members*

Team Leaders Information

Full name*

Date of birth*

Gender

Contact no.*

Email*

Residential address*

Emergency contact*

Emergency contact phone no.*

Team member information (1)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (2)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (3)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (4)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (5)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (6)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (7)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Team member information (8)

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Support member information

Full name*

Date of birth*

Gender*

Contact no.*

Email*

Condition of entering a team

Declaration

By signing the below, I confirm that all the information provided is accurate and complete.

I also acknowledge that I have read and understand the event rules and regulations. I hereby release the Shire of Coolgardie and the Department of Local Government, Sport and Cultural Industries from any liability relating to me and my team's participation in the event.

I also give permission to be photographed during this event. Images may be used in the future by the Shire of Coolgardie for marketing purposes.

Team leader sign*

Team member (1) sign*

Team member (2) sign*

Team member (3) sign*

Team member (4) sign*

Team member (5) sign*

Team member (6) sign*

team member (7) sign*

Team member (8) sign*

Support member sign*