Branch Facilitator Registration Form

First Name

Last Name

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QCWA Membership Information

Branch Name

QCWA Region Name

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Contact Information

Postal address

City

Post Code

Phone

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We are keen to know a little bit more about you

Why do you want to be a QCWA Country Kitchens facilitator?

Which groups or community organisations in your area would you like to work with?

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Use of Personal Information and Photo Consent

Please read the following information and tick the relevant boxes to indicate consent:

I agree to the QCWA Country Kitchens program using the information provided by myself for reporting purposes. You will not be identifiable in the reporting.

Optional:

I agree to the QCWA Country Kitchens program recording my image (photograph or video footage) for promotional purposes. This may include publications and promotional material, and broadcast, print and electronic media.

SUBMIT