Activity Registration Form

Activity Registration Form

Please note that completion of the headings with an asterisk is compulsory. The form cannot be submitted before these fields are completed.
Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Emergency Contact Name

First NameLast Name
Relationship to you
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you accompanied by a carer?
Carer's Name / Agency
Contact Details
Are you a financial member of Coolum HeARTS inc?
Fees per session:

Members - $10

Non-members - $20

Carers - $10

The carer fee entitles the carer to participate in the session as well as the client.
How will you be paying per term?
Which activities would you like to register for? (Please tick the relevant box and refer to the What’s On Program for fees and direct debit information.)
Should be Empty: