reg formr Registration Form This form uses conditional logic. Dependant on the 'Select Purchase' option/s chosen, the correct fields will appear. Please click in the check box adjacent to all categories you have just purchased. "*" indicates required fields Date*Enter the date of your Order. Day Month Year Order #*Enter the number displayed after # on the previous screen & in the Order Summary sent to you via email.Select your purchase.*Select the class, lesson, package or combination of any you have purchased. Beginner Ballroom Class Intermediate Ballroom Class Bridal Lesson Bridal Package Children's Class Private Lesson Participant's Name* First Last If a couple, 2nd participant's name First Last Date of WeddingDate of Wedding Day Month Year DOBRequired only if participant is under 18. Day Month Year Parent or Guardian nameRequired only if participant is under 18.Known conditionsPlease disclose any condition the participant/s may have which the instructor should be aware. Thank you.Media Permission*I give permission for any photographs and/or video recordings of me / us / my child, named above, taken by or on behalf of Penrith Ballroom Dance, to be used for the purpose of promoting, advertising, and marketing their classes and activities, in any digital or printed media, including but not limited to websites, social media, flyers, posters, and advertisements, with no entitlement Permission Granted Permission Not Granted Purchaser name*Enter the name of the person making the purchase.Mobile phone*Other phoneEmail* How did you pay for class?* Direct Bank Transfer Credit Card Other How did you first hear about Penrith Ballroom Dance?* Studio Signage Google Business Page Word of Mouth Website Google Ad Facebook Instagram Western Weekender Bridal Celebrant This field is hidden when viewing the formHow did you first hear about Penrith Ballroom Dance?*CAPTCHATerms & Conditions* I have read and agree to the published Terms and Conditions.Details required for Gift Certificate preparationGift Certificate from*Name of person giving the certificate.Gift Certificate to*Name of person receiving the certificate.Gift Certicate reason*Enter reason or occasion for certificate purchase.Additional commentsDo you have any questions or comments for us?Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Δ
