Registration Form

REGISTRATION FORM

LOOSE ACOUSTIC Registration FORM

I wish to register for the following Loose Acoustic event *

Winterbreak Music Retreat Master Songwriter's Retreat Master Fingerstyle Guitar Retreat Other

* Indicates required field

Name *

First

Last

Email *

Date of Birth *

Gender *

Female Male

Address *

Phone *

Mobile *

1. Rank your workshop interests (#1 being your primary interest) *

Songwriting Singing guitar

Other (please specify) *

Other, (please specify) *

4. What level of proficiency *

Beginner Intermediate Really Good

5. Do you have any special dietary/disability needs? *

6. Do you suffer from any of the following medical conditions or other conditions we should be made aware of? *

Please give details. *

Emergency Contact *

7. Payment. I am making payment by the following means. *

Credit card Cheque payable to Loose Acoustic Direct Debit - BSB 084 929 Acc No 1366 756 99 PayPal

Credit card type *

Amex Visa Mastercard

Name as on card *

Credit Card Number *

Expiry Date *

CRV *

Pay with my PayPal account
If you are paying with PayPal, please send to looseacoustic@bigpond.com in PayPal and put the name of the entrant in the “email to recipient” subject. Please put your transaction number here ____________________

Payment plan details *

Total amount paid *

8. Please add me to the Loose Acoustic mailing/newsletter list *

Yes No

9. In the case of an emergency, I authorise Loose Acoustic staff, where it is impractical to communicate with me, to arrangefor me to receive such medical or surgical treatment as may be deemed necessary. I also undertake to reimburse costs which may be incurred for medical attention, ambulance transport and drugs who;le I am attending the retreat. I understand Loose Acoustic and it's service providers will minimise the risk of personal injury for participants of this retreat. *

Yes No

10. I agree to allow Loose Acoustic to use my name and any photographs or sound and picture recordings taken of me during the retreat for the promotion of Loose Acoutic's services and initiatives to the media and general public *

Yes No

How did you hear about this workshop/retreat? *

Submit