Form Skiff Liteboat - Roeicentrum Berlagebrug

Personal information

Name*

Returning customer

Address*

Email*

Customer number*

Your customer number has 6 numbers completed with a capital P. You can find yours on the invoice we have send you last time of ask the head coach.

Phone*

Date of Birth*

Gender*

Liteboat cursus*

Course period*

Preferred day*

Preferred starting time

Preferred starting time evening

Preferred starting time

Preferred starting time evening

Preferred starting time

Flexible start time*

Alternative day*

Please let us know in the remarks if you want a different time on the alternative day

Remarks

How did you hear about us?

Choice of payment*

Method of Payment

American Express

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name of account holder*

IBAN bank account number*

Total

0,00 €