Holiday Clinics Registration Form

Holiday Clinics 2019

Registration Form
Student Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Mobile Number *

Area Code Phone Number
Phone Number

Area Code Phone 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