Grassroots Movements Conference Registration Form

Fill this form and click register at the end.

Payments can be made directly to our bank account details at the bottom of the form.

Many thanks for you interest and support

Name:

E-mail:

Mobil:

Gender: Male Female

Attending Friday Opening: $10 Full $5 Concession

Whole Conference: $20 Full $10 Concession

One day Conference: $10 Full $5 Concession
Which Day?: Saturday Sunday

Attending Saturday Dinner $25: Yes No

Required Lunch $10 (Latin food from Restaurant La Cantina): Yes No
Day: Saturday Sunday Both

I would like to help during the solidarity conference: Yes No

I would like to help promoting the Gathering : Yes No

I would like to get involved in LASNET : Yes No

Please add my E-mail to the LASNET e-mail distribution : Yes No

I/We would like Make a donation to LASNET and the Gathering :

$ 05
$ 10
$ 20
$ 40
$ 60
Any

Send Money Order/ Cheque to LASNET, P.O.BOX 813, North-Melbourne VIC. 3051.

Or Make a direct deposit into LASNET account at Bendigo Bank BSB 633-000 A/C Number; 133 147 793