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
DD slash MM slash YYYY
Date Activity Ends
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
DD slash MM slash YYYY