Please complete your details below to register for the Aconcagua Gutsy Challenge.

 

Please transfer your deposit of $500 to:

BSB: 082-372

Account number: 52-697-8943

Account name: Australasian Gastro-Intestinal Trials Group Operations Account

Reference: ACON_XXX ( XXX = the first three letters of your surname)

 

To pay via credit card, call Angie Fox on 1300 666 769.

 

A receipt will be sent to you via email.

 

If you have any questions, please call Nicky Lancaster on 1300 666 769

 

Your Details

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone
Additional Comments