Dirt Maidens Girls Skills Clinic booking Name * First Name Last Name Date of birth * MM DD YYYY Age * (age at program/session commencement) 9 10 11 12 13 14 15 Parent/Carer Name * First Name Last Name Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Emergency Contact Name * First Name Last Name Emergency Contact * (###) ### #### Do you have any medical condition/s that your instructor should be aware of (e.g. asthma)? * No Yes If you answered 'yes' to the above, please give details below. Where did you hear about us? * Dirt Maidens Fb page Facebook Ad Instagram Ad Friend/family member Word of mouth Other Thank you for booking a girls mtb clinic with Dirt Maidens! We are so excited for you to join us :)Your booking will be confirmed upon receipt of payment and further pre-clinic information will be emailed to you soon.PAYMENT DETAILS:Pay via direct deposit to:Dirt MaidensBSB: 082-902Account: 71-875-2981Looking forward to riding with you :)Warm regards, Claire
