program entry form

Saturday 21 October – Sunday 29 October 2017

Queensland Patron

His Excellency
The Honourable Paul de Jersey AC
Governor of Queensland

President & Co-Presidents

Michael Tizard & Stephen Alderman

National Ambassador

Megan Mitchell

Australian Commissioner for Children

State Ambassador

Ms Cheryl Vardon

Principal Commissioner Qld. Family & Child Commission

Junior Ambassador

Rosie Sellars

Vice President

Rosalie Raciti


Georgie Baker

Please contact Georgie Baker via if you have any questions.

Contact Person :

Name of Organisation :

Postal Address :

Telephone :

Mobile :

Fax :

Email :

Website :

Quantity :

Stickers :

Posters :

Balloons :

Event : ( Brief Outline of activities/events planned during Children's Week: More than 5 lines please use a separate sheet.)



Name & Address of Venue :

Contact number :


 Activities open to public Booking Required In-house activity only

(Please mark with X)

Terms & Conditions of CW Name and logo consent: To use the Children's Week Logo you must accept the conditions for the use it on any flyers, publicity etc.

I accept the conditions for using the Logo on your advertising to do with your event

 Yes  (Please mark with X)

Please indicate below if your organisation has Public Liability Cover:

 Yes  (Please mark with X)

Renewal Date:

Please indicate below if your organisation has Public Liability cover :

 Yes No(Please mark with X)


Please e-mail back to or print the form and post to QCWAI, 29 Somerton Street Bracken Ridge 4017
Phone: (07) 3261 7036 or 0438698643