Winter Conference - WA 2023 event registration

I am registering as: *

Which category do you fall into? *

First Name *

Last Name *

Preferred Email *

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

Phone number *

Please write in the format xxxx xxx xxx

Gender *

Date of Birth *

What size hoodie/jumper would you like to order? *

Which category do you fall into? (Spouse) *

First Name (Spouse): *

Last Name (Spouse): *

Preferred Email (Spouse) *

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

Phone (Spouse) *

What size jumper would you like to order? (Spouse) *

Is this your first Power to Change Conference? *

Which campus are you from? *

If you selected other, please tell us where you are from *

Is this your first year of university? *

Is this your final year of university? *

If you have been involved with us before, please indicate which Power To Change worker or leader you know best. *

The Power To Change leader I know best is: *

Are you an international student? *

'Is there any person(s) you would prefer to share accommodation with?

We will do our best to room you with your preferences but there is no guarantee.

Please list out any dietary requirements/ food allergies that you have that we need to be aware of

If this is for a couple or family registration be sure to include the person's name

Please list any medical conditions that you have that we need to be aware of

If this is a couple or family registration be sure to include the person's name

Do you have a valid first aid certificate?

If this is a couple or family registration be sure to include the person's name

I have completed the following training modules: *

How do you plan to travel to Winter Conference? *

I am driving and can take: *

How do you plan to travel from Winter Conference? *

I am driving and can take: *

Are you driving to/from conference and are under the age of 21 or have had your drivers licence for less than two years? *

Street Address *

Suburb *

Postcode *

Emergency Contact Name & their relationship to you *

Emergency Contact Phone Number *

Would you like to share anything else that might be helpful for the conference organisers to know?

Privacy Statement *

©Power to Change ABN 25126098398 is an international faith based mission that connects people to Jesus and each other. We respect your privacy and will only use your information to do what you have asked (eg, registration, donation, subscription) and to keep you informed of our work. We will not pass your details onto unrelated third parties and we will allow you to opt out of our publications. See our Privacy Policy at powertochange.org.au

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

Payment Method *

For Credit Card payments, please contact John Mayne. Fees may apply.

Amount

Discount Amount

Gross amount

Coupon

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

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