Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name of your guest (if you are bringing a partner, friend, parent or caregiver)
Will you be using a wheelchair at the event?
*
Yes
No
Do you or your guest have any food restrictions:
*
Gluten free / celiac
Dairy free
Peanut allergy
Tree nut allergy
Vegetarian
Vegan
Other anaphylactic food allergy (please list below)
None
Name of person who has allergy/food restriction and reaction:
Please complete the section below ONLY if you are purchasing your ticket by debit, credit card or Paypal. If you are paying by etransfer, submit this form now and send your payment to: info@sbhana.org
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( X )
Ticket
Includes dinner and dance
$
20.00
CAD
Quantity
1
2
Payment Methods
Debit or Credit Card
Please click one of the PayPal options to complete payment and
submit
the form.
Submit
Should be Empty: