Holiday Clinics Registration Form

Holiday Clinics 2019

Registration Form
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Mobile Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Holiday Clinics*
Additional Comments
Junior Clinics (9:00 - 12:00)

For CLTC Members - $171

For Non Members - $190
To Pay By EFT

Account Holder: Andre Vaz Pinto

BSB: 086 164

Account Number: 98 441 8388
Should be Empty:

Holiday Clinics 2019