Class: ……………………….           Day/Time: …………………………

 

Name:…………………………………………………………………………………….

 

Age Bracket 18-25  26-35  36-45  46-55  56-65  66-76  76+  (please circle)

 

Asthma / Allergies to Nuts/Dogs or Other? (circle) no yes epi pen

 

Further Details ...................................................................................... .

…………………………………………………………………………...........

 

Home Address……………………………………………………………………………

 

……………………………………………………………..Postcode…………………

 

Tel: Mobile…………………………

Work/Home………….....................................

 

Email………………………………………………………

 

Emergency Contact Name……………………………

Tel…………………………

 

Other……………………………………………………………………………………….

 

How did you hear about us? ……………………………………………………………

 

What are the areas you would like to explore during this course?

 

………..………….…………………………………………………………………………

 

I wish to pay by: Cash Credit Card Visa MasterCard Direct Deposit

 

Amount: $..................... Paid in Full by Cash Direct Deposit

Credit Card Gift Voucher

 

Card Number .... …. …. …./…. …. …. …./…. …. …. …./…. …. …. ….

 

Expiry Date …. …./…. …. Cardholders Name………………………….

 

Cardholders Signature………………………...................Date………….

 

Office Use Only:

 

Receipt Number……………………………. Date…………………………….