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Ageing Disgracefully 2016

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* 1. First name

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* 2. Last name

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* 3. Number of people registering

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* 4. Email address

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* 5. Street Address

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* 6. Suburb

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* 7. Post code

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* 8. Contact number

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* 9. Have you attended Ageing Disgracefully previously?

Yes

No

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* 10. How did you hear about Ageing Disgracefully?

Have a Go News

Local paper

Word of mouth

Radio

Road side signage

Community Group

Within leisure centre

Flyer/ Poster

Internet

Weekend Notes

Other (please specify)

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* 11. Would you like receive further communication regarding City of Swan Leisure Centres, including upcoming Feeling Fabulous events? You may unsubscribe at any time.

Yes

No

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