Skydive for Palestine

Registration

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Confirm Email

Mobile Phone *

The Skydiving company have requested the following information

Date of Birth *//

Weight (kg) *

There is a 15kg restriction

Height (cm) *

Do you have any known medical conditions? *

If you have selected 'Yes', please provide further details

Emregency Contact Name *

First

Last

Emergency Contact Mobile Phone *

I agree to fundraise a minimum of £500 for Medical Aid for Palestinians using the JustGiving page *

I agree that the registration fee is non-refundable *

The payment is made using a secure

Skydive for Palestine 2019 - Registration Fee

Price: £ 230.00

The price covers the full cost of the Skydive

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

Message