New Customer Registration Form

The Lift to Literacy Competency with Dr Pam Kastner. Registration form.
Full Name *

First Name Last Name

School/Place of work *


Address
Suburb	City/Town
Postal Code	Country

Workshop you wish to attend.
Phone Number *

Area Code Phone Number
E-mail
How did you hear about us? *
Other *
Do you have any dietary requirements?
Anything else we should know?

Please give reference of any two people whom you feel might want to attend:

	Full Name	Address	Contact Number
1
2

I wish to book;

Earlybird (pay by end of Term 4 2019) NZD$125 Regular fee (pay between December 20, 2019 to February 29, 2020 NZD 150 Late fee (pay in March 2020) NZD$175
Should be Empty: