Koncert Piosenki Filmowej

How many people are you registering? *

(including yourself)

Pana/Pani Rejestracja | Your Registration Info

Imię | First Name *

Nazwisko | Last Name *

An email address is required to send a receipt. Please do not use the same email address for multiple participants.

Adres Email | Email Address

Event Fee(s) *

Członek klubu - wejściówka i obiad | Club Member - admission and dinner - $ 40.00

Członek klubu - tylko wejściówka | Club Member - admission only - $ 20.00

Gość niezrzeszony - wejściówka i obiad | Nonmember - admission and dinner - $ 45.00

Gość niezrzeszony - tylko wejściówka | Nonmember - admission only - $ 25.00

Dzieci i młodzież do 18 lat - obiad | Children and youth up to 18 years old – meal - $ 20.00

Total for this participant

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

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