Please fill in the details below to request further infomation about our services.
Name:
Phone (Day):
Phone (Night):
Phone (Mobile):
Email:
(Confirm email address)
Street address:
Suburb/Town:
State: ACT Queensland South Australia New South Wales Northern Territory Tasmania Victoria Western Australia Non-Australian
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Please send cheques/money orders/credit card authorities to: PO Box 8313 Perth Business Centre WA 6849 Ph: 08 9228 9999 / Fax: 08 9228 9988
Please tick which Awareness Event/s you wish to participate.
Do you intend to participate as a group? Yes No
Player 1 name:
Player 1 handicap:
Player 2 name:
Player 2 handicap:
Player 3 name:
Player 3 handicap:
Player 4 name:
Player 4 handicap:
$250 (Individual)
$4000 (A Team) (banner sponsorship)
$2000 (B Team) (banner sponsorship)
$1000 (Group)
(International Day of Persons with Disabilities)
* For more information and terms about each of the events, please call us 08 9228 9999.
When you submit this form, you will be registered to the event you selected. And you will be able to process donation via secured internet payment system.