Engage 2012

REGISTRATION FORM

Engage 2012

Please fill out the registration form then make payment through Paypal or by Bank transfer.
Your registration will not be accepted if payment does not go through.
Siblings must register separate from the rest of their group in order to receive the discounted rate.

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Registration Options

Single Siblings Group

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:
Dietary requirements:
Gender:
Age:
Budget Accommodation:

Participant Details

Number of participants:

Number of children:

  Firstname Lastname Gender Age Dietary requirements Accommodation
1 Adult 1 (included)
2 Adult 2 (included)
3 Child 1 (included)
4 Child 2 (included)
5 Child 3 (extra $0)
6 Child 4 (extra $0)
7 Child 5 (extra $0)
8 Child 6 (extra $0)
9 Child 7 (extra $0)
10 Child 8 (extra $0)
11 Child 9 (extra $0)
12 Child 10 (extra $0)
13 Child 11 (extra $0)
14 Child 12 (extra $0)
15 Child 13 (extra $0)
16 Child 14 (extra $0)
17 Child 15 (extra $0)
18 Child 16 (extra $0)
19 Child 17 (extra $0)
20 Child 18 (extra $0)

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
Reference should include event name & delegates surname.