CL&AG - Registration Form - Brick by Brick

Child's Full Name*

Age*

Parent or Guardian Contact Name*

Parent or Guardian Contact Number*

Email Address*

Please select at least ONE of the FOUR challenges:

Week 1+2 (10 & 17 Feb)Week 3+4 (24 Feb & 3 Mar)

Please select at least ONE of the FOUR challenges:

Week 5+6 (10 & 17 Mar)Week 7+8 (24 & 31 Mar)

Photo Consent - I give consent for images to be taken and for these images to be used, modified, and distributed by the Shire of Carnarvon.*

YesNo