JUMP FOR JANE 2014 REGISTRATION FORM Congratulations and thank you for being part of Jump for Jane 2014. Please complete the information below including your credit card information and return the form to Breast Cancer Care WA (details below). Please let us know if you wish to pay your registration fee another way. By completing and signing this form, you are providing Breast Cancer Care WA with permission to charge your credit card $199. You are also confirming that you agree to raise an additional $1,000 to support the services provided by Breast Cancer Care WA. We recommend that you reach your $1,000 minimum fundraising target by 20 October (the peak time to fundraise is prior your tandem skydive) . Next you will be sent a link to setup your online fundraising and don’t forget to also use Facebook. Aim high, the skies the limit! Please complete all sections. Name: _______________________________________________ Date: __________________ Email: _____________________________________ Contact Phone: _____________________ Address: _______________________________________________________________________ _______________________________________________________ Post Code: ____________ T-shirt size _______________________ Payment details for $199 I give my permission to Breast Cancer Care WA to charge my credit card below a $199 deposit: CREDIT CARD DETAILS Visa Mastercard Card number Expiry date ____________________ Security ID ___________________ Name on card __________________ Signature ____________________ Please fax your completed form to 9485 2593 or email a copy to [email protected] ASAP.