Queensland Pole Dance Championships Registration Form*

Personal Details

* First Name		* Surname
Preferred/Stage Name
Address
Postcode
* Contact Phone Nr
* Email Address

* Competition Level
Years Dancing
Other Prior Experience
Why did you take up Pole / What do you like about it?
Your Pole School

* Preferred Heat

* Please List Song and Theme preferences:
1)
2)
3)

I agree to the terms and conditions of the Miss Pole Dance Australia competition and those laid down by Scoundrelles, and I agree to abide by these conditions.