Public Liability Form

Name*
Contact Number
Activity/Event Name
Church/Organization Name
Activity Location
Activity Description
Email address to send the PLC to
Date Activity Commences
Date Format: DD slash MM slash YYYY
Date Activity Ends
Date Format: DD slash MM slash YYYY
SDA Group organising or involved in this activity:
Has your local Conference ADRA Director approved the activity?
- Yes
- No
Who is the non SDA organisation requesting this certificate? e.g. local council name or Foodbank
Non SDA organisation Street Address
Non SDA organisation Suburb
Non SDA organisation State
Non SDA organisation Postcode
Date PLC is required by
Date Format: DD slash MM slash YYYY