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2009 XBR COACHING SUPER-CLINIC ONLINE REGISTRATION
& PAYMENT GATEWAY

FILL OUT THE FORM BELOW AND YOU WILL BE TAKEN TO XBR'S PAYPAL GATEWAY FOR PAYMENT
YOU CAN PAY BY CREDIT CARD (VISA or MC) or PAY USING YOUR OWN PAYPAL ACCOUNT

Please enter your details below.

*Required information

*NAME OF PARTICIPANT 1: 

*AGE:

*CLASSES RIDDEN IN THE LAST 12 MONTHS

*ARE YOU GOOD or AVERAGE for your age?

*HOW LONG HAVE YOU BEEN RIDING?

*NAME OF PARTICIPANT 2: 

*AGE:

*CLASSES RIDDEN IN THE LAST 12 MONTHS

*ARE YOU GOOD or AVERAGE for your age?

*HOW LONG HAVE YOU BEEN RIDING?

*Name of Parent or Guadian: 

*Address

*Suburb:

*Postcode:

*State:

*Phone No:

*Email:

 

*Any other relevant info Eg Food Allergies, medication

 

I would like to pay by

PAYPAL or CREDIT CARD
CHEQUE

 

I would like to receive information via email

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No

 
 

 

 

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