ACT Registration Form

Title Mr Mrs Ms

First Name

Surname

Street

Suburb

State

Post Code

Phone (no spaces)

I am registering as:

Team Name (optional)

Walker 1 Name

Walker 1 Email

Walker 2

Walker 2 Email

Walker 3

Walker 3 Email

Walker 4

Walker 4 Email

Walker 5

Walker 5 Email

I will be collecting donations

If you will be collecting donations please select the number of receipt books (20 receipts per book) you require

Would you like to purchase T-Shirts with your registration? If yes, select size and amounts below.

Small T-Shirts $25 each

Medium T-Shirts $25 each

Large T-Shirts $25 each

XL T-Shirts $25 each

I would like to make a donation in the amount of