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Dare to Dive Registration 2019

Thank you for taking the first step towards your skydive for Alzheimers Northland!

Please complete this form to register for Dare to Dive 2019. At the end of you form there is a second step to complete to pay your deposit which secures your place. If you are registering as a team we will need a contact name even if you haven't yet confirmed who is going to be carrying out the skydive. Please be sure to read all our terms and conditions before comitting to the skydive.

Contact Information

Name

First Name

Last Name

Organization/Employer

If you are registering as a workplace team

Verify Email

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

Do you have a special reason for supporting Alzheimers Northland?

Terms and Conditions

Please read the terms and conditions of this event (link at top of form)

I confirm I have read and agree to the Terms and Conditions for Dare to Dive 2019

I pledge to raise a minimum of $600 for Alzheimers Northland in order to qualify for a free skydive

Privacy

Alzheimers Northland will use the details given to administer this event and contact you with matters relating to this event. We will not pass on your details to any other parties. We would like to contact you in the future to let you know about events, news and activities relating to our organisation.

Email: Yes please email me events, news and activities from Alzheimers Northland

Amount - this is a deposit to secure your place and will be refunded to you on completion of your skydive - see Ts&Cs