Leadership Summit 2022 event registration

I am registering for *

Which category do you fall into? *

Which strategy are you apart of?

First Name *

Last Name *

Are you applying for a Leadership Summit Scholarship?

Where are you/your family currently living?

Phone Number *

Preferred Email *

As all future communication and emails will be sent to this address, be sure to check that it is correct.

Which category do you fall into? (Spouse)

Which strategy are you apart of? (Spouse)

Are you applying for a Leadership Summit Scholarship? (Spouse)

First Name (Spouse) *

Last Name (Spouse) *

Mobile Phone Number (Spouse) *

Please write this in the following format xxxx xxx xxx. E.g. 0404 121 114

Email (Spouse) *

All future communication and emails will be sent to this address.

How many children will you be bringing?

Child's Name (1) *

Child's Age (1) *

as of October 2022

Child's Name (2) *

Child's Age (2) *

as of October 2022

Child's Name (3) *

Child's Age (3) *

as of October 2022

Child's Name (4) *

Child's Age (4) *

as of October 2022

Child's Name (5) *

Child's Age (5) *

as of October 2022

Do you (or, if applicable, your spouse) have a First Aid Qualification which will be current until the end of conference? *

Please write the name of the person/s with the valid first aid certificate.

Does anyone in this registration have any medical conditions?

If this is a couple/family registration, list each person and their medical conditions.

Does anyone in this registration have any dietary requirements?

If this is a couple/family registration, list each person and their dietary needs.

Preferred Roommate

If you have a preference as to who you want to share a room with. If you are a snorer please indicate here as well.

Transport to Conference *

I need a lift from *

Number of Passengers (To) *

Number of Passengers to Conference (Bus) *

Including kids who won't sit on parent's laps (1 years and above)

Transport From Conference *

I need a lift to *

Number of Passengers (From) *

Number of Passengers from Conference (Bus) *

Including kids who won't sit on parent's laps (1 years and above)

Please give the details of someone we can contact for you (or your spouse/family) in the event of an emergency. The person must be 18 years or older and is not attending conference. It is ok if they do not live in Australia.

Emergency Contact Name *

Relationship to you *

Emergency Contact Number *

Can you think of any additional info that might be helpful for the Conference organisers to know about your registration?

I will be paying via *

For Australian participants only. You will be emailed the details.

Ministry Account Number

If you are not paying from your personal ministry account please write in the details here.

Privacy Statement *

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Please tick the box above to accept these terms and conditions.

Amount

Payment Method

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Credit Card Number*

Expiration Date*

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Card (CVV) Code*

Card Type*

Card Holder Name*

*

Verification code*

Registration

Emergency Contact

Payment Information

Payment Information