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. 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 Rock ‘n Roll for Beginners Intermediate Rock 'n Roll 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 conditionsRequired only if participant is under 18. Please disclose any condition your child may have and which we should be aware.Purchaser name*Enter the name of the person making the purchase.Mobile phone*Other phoneEmail* How did you pay for class?* Credit Card Direct Bank Transfer Unselect How did you hear about Penrith Ballroom Dance?*Terms & Conditions* I have read and agree to the published Terms and Conditions.CAPTCHADetails 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? Δ
