[stripe name=”Moontour” description=”Primary Summer Course” amount=”19000″]
[stripe_text label=”Student name:” id=”student_name” required=”true”]
[stripe_text label=”School:” id=”school” required=”true”]
[stripe_number label=”Student age” id=”age” required=”true”]
[stripe_dropdown label=”Class (next school year)” options=”6th Class, 1st year”]
[stripe_text placeholder=”Additional information. Please include any health issues, allergies or special requirements” multiline=”true” rows=”5″]
[stripe_text label=”Emergency contact name:” id=”Emergency contact” required=”true”]
[stripe_text label=”Emergency contact number:” id=”Emergency number” required=”true”]
[stripe_text label=”How did you hear about us?” id=”Heard from” required=”true”]
[stripe_dropdown label=”Which course would you like to book?” options=”Cúrsa F 17/8/15 – 21/8/15 5th & 6th Class”]
[stripe_coupon label=”Please enter discount code & press apply” apply_button_style=”stripe”]
[/stripe]