Name:
Biz/ School/ Pub/ Group:
Email:
Post Code:
Telephone:
Mobile:
Fax:

*Fields in blue are not required

Are you interested in volunteering on our TLAPD Street Collections Team? Mon Sept 1st &/or Fri Sept 19th. We will call you to discuss.                   

Are you interested in organising a TLAPD fund raising event? You may find the info you need amongst the forms on the right of your screen!              

OR I can't participate this year but will make a donation of $


1. Cheque  (make cheques payable to: Childhood Cancer Support) OR
2. Bankcard Visa Mastercard  AMEX   Diners Club


Card Number:     

Card Holder's Name:   

Card Holder's Address:   

Card Expiry Date:   


Aaarrrr, we be thankin’ you for your support!

Any problems please call 07 3252 4719 (day time) or email: pirates@talklikeapirateday.org