East Coast Pole Cruise 2019 Registration
The Ultimate Poling Adventure
www.eastcoastpolecruise.com.au
Email address *
The First Name (as Per Passport) *
Your answer
Surname (as Per Passport) *
Your answer
Phone Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Address *
Your answer
Cabin Type *
Roommate/s *
Your answer
Bed Configuration *
Pole Studio *
Your answer
Pole Level (estimate your level for March 2019) *
This can be changed closer to our sail date.
Travel Insurance Quote (recommended) *
Australian Citizen *
Dietary Requirements
In Case of Emergency (Name and Contact Number) *
Your answer
Payment Method
Credit Card (1.5% surcharge)
Direct Deposit
Full Payment
Monthly Payment Plan ( $150 fee)
Terms & Conditions *
Required
A copy of your responses will be emailed to the address you provided.
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