Discipling the Nations 2011

REGISTRATION FORM

Discipling the Nations 2011

Please fill out the registration form.
Your registration will not be accepted if payment does not go through.

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Registration Options

Single Group / Family (includes creche)* Married Couple

*If you need creche (for children under 6 years), please use Group/Family. Price will automatically adjust based on the age.

Contact Details for Registration

Registration Details

Group Coordinator's Details

*First Name: - This can't be blank.
*Last Name: - This can't be blank.
*Street Address: - This can't be blank.
*Suburb: - This can't be blank.
*State:
*Post Code: - This can't be blank.
*Country: - This can't be blank.
Phone:
*Mobile/Phone: - This can't be blank.
*Email: - This has to be a valid email address.
Church name:
Church suburb/town:
Senior minister's name:
Only list credit card holders details if you intend to pay using the credit card option.
Name on Credit Card: - This can't be blank.
Cardholder's Phone No.: - This can't be blank.
Youth Coordinator's full name:
Gender:
Age:
Southern Lights free accommodation & transportation offer
(ONLY for International delegates):
Concession:

Participant Details

Number of participants:

Number of children:

* Please note accommodation is for International Delegates only.
  Firstname Lastname Gender Age Concession Accommodation
1 Adult 1 (included)
2 Adult 2 (included)
3 Child 1 (included)
4 Child 2 (included)
5 Child 3 (extra $30)
6 Child 4 (extra $30)
7 Child 5 (extra $30)
8 Child 6 (extra $30)
9 Child 7 (extra $30)
10 Child 8 (extra $30)
11 Child 9 (extra $30)
12 Child 10 (extra $30)
13 Child 11 (extra $30)
14 Child 12 (extra $30)
15 Child 13 (extra $30)
16 Child 14 (extra $30)
17 Child 15 (extra $30)
18 Child 16 (extra $30)
19 Child 17 (extra $30)
20 Child 18 (extra $30)

Cost:
Total Participation Cost(AUD$):


Payment Options:
  
Credit card: You don't need a paypal account to use the Paypal Checkout Page. .
To pay using a Credit or Debit card, click "Don't have a Paypal Account" in the next page.
Bank transfer: Southern Lights BSB. 033138 Account # 267016
Cheque: Please send cheque made payable to 'Southern Lights' immediately.