Pole Cruise 2026 Registration Form

Pole Cruise 2026 Registration Form
Full Name (as per ID - Licence, Passport, Birth Cert etc)*

First NameLast Name
Email*
example@example.com
Citizenship (Australian, English, American etc)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
DOB*

DayMonthYear
Date
Pole Level (Estimate only) *
Roommate #1 (if applicable) - leave blank if you need us to find you a roomie

First NameLast Name
Roommate #2 (if applicable)

First NameLast Name
Roommate #3 (if applicable)

First NameLast Name
Dietary Requirements*

VeganVegetarianGluten FreeDairy FreeNoneOther
Other
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Terms & Conditions*

I have read and agree to the Pole Cruise Terms and Conditions (www.eastcoastpolecruise.com.au)I understand that in the event I need to cancel this booking I will forfeit my deposit outlined in the terms and conditions
Signature*

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