eMember

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Country*

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Email*	First Name*	Last Name*

Postal Address*		Suburb*

State*	Postcode*
Select State NSW ACT VIC QLD TAS SA WA NT

Date of Birth* (If you are younger than 16, a parent or guardian must register on your behalf)
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Month January February March April May June July August September October November December	Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Gender*
Female			Male

Which types of dance or fitness do you participate in? (please tick a minimum of one)
Dance: Classical Ballet Swing/Rock n Roll/Jive Contemporary/Modern Country Character Line Dancing Jazz Irish Tap World/Folk Funk World/Folk - Other (please specify e.g. Scottish, Greek) Hip-Hop   Break Callisthenics Musical Theatre Physical Culture - BJP Ballroom Physical Culture - Edith Parsons Latin Rhythmic Gymnastics Salsa Gymnastics Tango Cheerleading Spanish/Flamenco Ice Dance/Skating Please select relevant dance syllabi: Please tick a minimum of one. Mouse over to the syllabus name for complete description ADAP AICD ATOD BAL BBO Cecchetti CSTD FATD FSTD ISTD RAD SATD SFD VBA Other (please specify)   Don't know		Fitness: Yoga Pilates Group Fitness Classes RPM/Spinning Cardio Fitness Weight Training Tai Chi Other (please specify)
Please indicate which of the following applies to you: (please select a minimum of one)
Dance: Student Dancewear Retailer Full Time Student Ballet Mistress/Master Parent/Guardian of a Dance Student Choreographer Social Dancer Artistic Director Professional Dancer Dance Administrator/Co-ordinator/Educator Teacher Wardrobe Mistress/Master Studio Owner/Principal Medical Practitioner		General: Fitness Instructor Personal Trainer Retailer Buyer Fitness Centre Owner/ Manager Other (please specify)

 

Name of the school/institution you attend: (e.g. Mary Jane’s School of Dance / Fitness First Chatswood)
Have you ever shopped at a Bloch store?	Yes		No
Do you currently shop at a Bloch store?	Yes		No

If yes, which store

Select Store NSW Sydney CBD, Skygarden Shopping Complex Bondi Junction Brookvale, Warringah Mall Campbelltown, Macarthur Square Charlestown, Charlestown Square Chatswood, Westfield Chatswood Erina, Erina Fair Shopping Centre Hornsby, Westfield Hornsby Liverpool, Westfield Liverpool Miranda, Westfield Miranda Parramatta, Westfield Parramatta Penrith, Westfield Penrith ACT Woden, Westfield Woden VIC Southbank, Southgate Arts & Leisure Precinct Chadstone, Chadstone Shopping Centre Doncaster, Westfield Doncaster Maribyrnong, Highpoint Shopping Centre Southland, Westfield Southland QLD Fortitude Valley, Emporium

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