Your information

Club/Association: Click here to enter text.

Name of main contact: Click here to enter text.

Position: Click here to enter text.

Mobile: Click here to enter text.

Email: Click here to enter text.

Responsible Service of Alcohol (Please tick if YES)Not applicable for Clubs/Associations without a liquor license

☐ Is an Approved Manager on duty at all times during licensed opening hours? ☐ Is the Duty manager signage on display? (Please provide photographic evidence) ☐ Is the correct signage displayed at or near the front entrance of the licensed premises? (Sample available at www.clubswa.com.au/members/liquor-licensing/records-and-signage/) ☐ Is your Training Register and Incident Register up to date?

Member Safety (Please tick if YES)

☐ Are club members encouraged to sign and display the Road Safety Pledge? (see attached template provided by Clubs WA) ☐ Are there designated smoking areas?

Road Safety (Pick one of the following and supply photographic evidence)

☐ Road safety promotions on social media platforms ☐ Road safety poster/s in a prominent area within your clubhouse

(Road safety posters can be found here www.rsc.wa.gov.au/resources#icons)

ANSWERED ALL THESE? FANTASTIC!!

Congratulations on being a Club Trail BlazerTo receive your Club Trail Blazer Certificate, Electronic logo of the Clubs WA STRIVE

Program – Club Trail Blazer, Clubs WA STRIVE Program – Club Trail Blazer Decal Stickers and Clubs WA STRIVE Program Posters,

please email the completed form to events@clubswa.com.au

PLEDGETake the PLEDGE to take care of each other.

Be part of the force to beat road trauma and to ensure the road is safe for everyone.

I take the pledge to choose Road Safety by promising to:

Be aware of my peers’ safety Check on my peers before they drive off Always be fit to drive Scan the road ahead Know my limits and plan my trip Stay sharp and take regular breaks Not drive through flooded waters Be alert for wildlife and livestock Drive to suit the conditions

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Name Club/Association Name

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Signature Date

Road Safety Commission is a proud Partner of Clubs WA