Name: ______Age Group: ____ (Please Circle): Male/Female Surf Club: ______

Medicare No: ______Email: ______

Address: ______

Parents Name: ______Phone: ______Mobile: ______

·  Have you ever had or do you currently suffer from:

High Blood Pressure, High cholesterol, Rheumatic Fever, Liver/Kidney condition, Diabetes or Epilepsy? YES/NO

Please Specify: ______

·  Do you have any heart problems, any family history of heart disease or stroke? YES/NO

Please Specify: ______

·  Have you had any breathing difficulties or asthma, major injuries, regular headaches, cold, flu? YES/NO

Please Specify: ______

·  Are you taking any medication? YES/NO

Please Specify: ______

·  Is there anything else that you may want us to know? YES/NO

Please Specify: ______

WAIVER: Although all care is taken during the clinics, the clinic organizers and assistants will not be held responsible for any injuries arising from the clinic. I hereby give my CONSENT for my son/daughter (named above), to attend the Shannon Eckstein Ironman Clinic. I also understand that surf conditions may force a change in venue for safety reasons. My son/daughter is a current financial member of their club. I have read and understood all the information on this form and have answered each question to the best of my knowledge.

PARENT/GUARDIAN: ______Date: ______

Method of Payment

  • Please send this Registration/Medical Form along with your PAYMENT (cheque/cash/money order) MADE TO BULLI SLSC P.O. 355,WOONONA NSW 2517
  • Email this form to
  • Direct deposit via Internet banking: Bulli SLSC - ICU BSB: 802249 Account Number: 249028092
  • Credit card payment go to pay.slsa.com.au select entity to pay “BULLI” transaction type “SPECIAL EVENT” and then follow instructions.

Please note that an email will be forwarded to you on confirmation of your place in the clinic.

Please submit one form per participant

Cost $70 per person

For further details please see the Shannon Eckstein Ironman Clinic Poster, Instagram, Facebook or www.shannoneckstein.com.au or contact Bulli Surf Club www.bullisurfclub.com.au

ALL PARTICIPANTS DOING SURF ACTIVITIES MUST BRING THEIR OWN HI VIS RASH VEST AND BOARD TO THE CLINIC