"Hey kids please
get a carer or parent to
fill in this form
for you"

Registration Form

Salutation *

Family Member *

First Name *

Last Name *

DOB dd/mm/yyyy *

Gender * Male Female

Email *

Family Username *

Password *

Confirm Password *

Address Line 1 *

Address Line 2

Suburb *

State *

Post Code *

Phone Number *

Family Challenge Start Date *

Fundraising Target *

Promotion Code (If applicable)

Are you a Bupa member? Yes No

If yes enter your membership number

Has your childs school ever had
a visit from the Life Education Van? Yes No

If yes which school?