External Event Acceptance

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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.
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