15 A Day @ Home – Online Registration Form

Child's First Name*

Child's Last Name*

Child's Age*

Parent / Guardian Name*

E-mail Address*

Password*

Confirm Password*

Address*

Suburb*

Postcode*

Country*

Mobile Number*

Phone Number

School Name*

School Suburb*

Country*

PayPal Payment - Must be completed once you've completed your Registration

Only fill in if you are not human

Physical Activity Specialists