Test Sub Page

This is a test form

Name*
First Name (person with tics) Last Name (person with tics)
(if under 18 please complete caregiver details below)
Date of Birth*

Day
Month
Year
Ethnicity*
Preferred Pronoun(s)
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Phone
Diagnosis:
- Tourette Syndrome
- Tic disorder
When was Diagnosis made
For Parent/Caregivers
Parent/Caregiver Name
Parent/Caregiver Last Name
Parent/Caregiver Email
Parent/Caregiver Phone
How did you hear about us
Payment
Membership price*
Would you like a t-shirt?*
- T-shirt
- No T-shirt
T-Shirt Size*
Total
$ 0.00
How would you like to pay?*
- Credit Card (recurring)
- Direct debit
Renewal of $75 per annum
Credit Card
Card Details
Cardholder Name
Payment by Internet Banking to:

Tourette’s Association of NZ
BNZ 02-0865-0077699-01

Please use surname and initials of TS individual as a reference.