Clone of Pause for Life Registration PA Members

Pause for Life Registration Form

This form is for current Paddle WA members. Please fill out the form carefully. Please note your registration is not finalised until payment has been completed and paid for.
Please provide your Paddle Australia number (PA******)
If you do not have or remember your Paddle Australia number, please contact us on 9285 8501.
NOTE: If you are not a current direct or club member of Paddle WA, please Use this form instead.
Your Name

First NameLast Name
Email
example@example.com
Phone Number
Enter your mobile number
Birth Date

MonthDayYear
Gender
Pause for Life is a female specific program
Cultural Background
Address

Street Address

Street Address Line 2

CityState

Post Code
Please advise your preferred location.
Do you have any dietary requirements?
Please complete any specific dietary requirements and/or allergies. Or write NIL.
Do you have any medical conditions we should know about?
Please list any conditions or write NIL. We need this information to help us provide a safe and comfortable environment for you.
Emergency contact

First NameLast Name
Emergency contact Phone
The Pause for Life program is proudly sponsored by:
Payment: choose your prefered payment method to pay your $130.00 registration fee to secure your spot in our program.

If you have any problems with the payment process, or prefer to pay by an alternative method, please leave payment box unchecked, submit your form and contact us on 9285 8501 or email admin@paddlewa.asn.au
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Pause for Life registration
Menopause health and wellness program.

$130.00 AUD Quantity

Total

$0.00 AUD

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Pause for Life Registration Form

Payment: choose your prefered payment method to pay your $130.00 registration fee to secure your spot in our program.

Payment Methods