First Name Last Name

Date of Birth male female

Unit/Number Street Name

City State Post Code

Home Phone Mobile Phone

Email

Payments Details

Total Fee: AUD $150 - includes Capoeira classes, music classes and instructional DVD.

8 Weeks Beginner's Course (1 class/week) Adult Kids OR

4 Weeks Beginner's Course (2 classes/week) Adult Kids

Location of Training (for more details go to Timetable)

Date of Commencement (for more details go to Timetable)

Cash (Pay in person)

Visa (please, don't send us your Visa/Credit Card number by email, for your security you must print this form and fax us on 02 9130 1327)

Credit Card No expiry date

Name on Card

Cheque (please make the cheque payable to Capoeira Brasil)

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