Name:
Address:
Home Phone:
Moblie:
Email:
Sex:
Male
Female
Date of Birth:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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31 Month
January
February
March
April
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June
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August
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December Year
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
Industry Type:
2010 NZYF Member:
Yes
No
Membership Number:
NZYF Club:
==select==
Awakeri
Balfour
Ballance
Bream Bay
Clinton/South Otago
Dunedin
Dunsandel
Duntroon/Tokarahi
Eltham
Eskview
Fitzherbert
Five Forks
Foothills
Glenavy/Waimate
Grey Valley
Hauraki
Hinds
Hurunui
Levin
Lincoln
Lyalldale
Mackenzie
Marton
Massey University
Methven
Milford/Clandeboye
Moa Flat
Napier Boys High School
New Plymouth
Ngarura
Nightcaps
North King Country
North Taranaki
North Waikato/Taupiri
Opiki
Piarere
Pendarves
Pihama
Renwick
Roto-o-Rangi
Rotorua
Southland Girls
St Kevins
Taratahi-Masterton
Taratahi-Stratford
Tarras
Te Kawa West
Te Puke
Thornbury
Tikokino
Upper Manuhekiri
Waihora
Waimakariri
Waitaki Boys
Waitane
Wanganui
Wellington
Wellsford
West Melton
Whangarei
No Club
District Final you wish to enter:
==select==
Bay of Plenty
Christchurch
Far North/Whangarei
Hawkes Bay
Horowhenua
Lower North
Manawatu
Marlborough
Mid Canterbury
North Canterbury
North Otago
Rangitikei
South Otago
Southern
Taranaki
Tararua
Timaru
Waikato/Piako
Waipa/Waitomo
Wairarapa
West Coast
Shirt Size:
Small
Medium
Large
X Large
XX Large
XXX Large
Emergency Contact Name:
Emergency Contact Number:
I would like to apply for a Lincoln University Scholarship for Excellence
Yes
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