Disability and Sexuality Forum

Online Registration Form

To register to attend the forum please complete the online registration form below.

* Indicates compulsory fields.

An invoice will be emailed to you on completion of this registration form

First Name*:    

Last Name*:    

Email*:           

Telephone*:    

:

Address*:        

Suburb*:         

Postcode*:     

Organisation: 

Cost: $11 concession **

**To be eligible for a concession you must receive a full Disability Support Payment or be a full time Carer.

:         

:

Method of payment: (Visa or Mastercard)*

*Refer Credit Card Payments Procedure (right hand column)


By registering you are agreeing to fields's cancellation and refund policy.

When & Where

Date:
Thursday 18 March, 2010
Time:
1 – 4 pm
Venue:
Darebin Arts & Entertainment Centre
Corner of Bell St & St Georges Rd Preston 3072
Parking on site - (Melways Ref. 30 E1)
Cost:
$55 - full
$11 - concession*

*To be eligible for a concession you must receive a full Disability Support Payment or be a full time Carer.

Further Information

For further information about registration please contact
field:
Tel: 03 8686 5622
Email:linda.budd@field.org.au

For further information about forum content please contact:
Josie Prioletti:
Mobile: 0438 846 584

Credit Card Payment Procedure

Step 1

Complete on-line registration form.

 Step 2

Wait for Tax Invoice, which will be emailed to you within 15 mins of completion of registration form. You will need the Tax Invoice number to complete step 3.

 Step 3

Telephone field, 8686 5621, quote Tax Invoice number and credit card details to complete payment.

 

 

 


 


field Suite 902, 530 Little Collins Street Melbourne 3000 T: 8686 5621 F: 8686 5625 E: linda.budd@field.org.au