When

Book Wheelienet

CONTACT DETAILS

Name of Organisation/School:

Contact Person:

Position: 

Phone no. - Business hrs:

Phone no. - After hrs:

Mobile no.:

Fax no.:

Street Address of Organisation/ School:

Suburb:

Postcode:

E-mail:

WHEELIENET PRESENTATION DETAILS

Date/s and Time/s of Visits/s

Date Day Time From Time To

Proposed Session Outcomes (variations are acceptable) - Please Tick:
 Talk/Discussion Wheelchair Skills Education-based Accident Prevention Safety Sport Specific (e.g. Basketball) Sports Day

Year level of class (if school group):

Approximate Age Group:

Number expected in attendance:

Venue Address (where the WheelieNet session will be held) - if same as address of Organisation/School please type 'as above':

Where is parking available for Wagon and Trailer? (Link map if possible):

Where to meet contact person?:

Any Additional Information?: