Term 1 2018 Adult

Client 1 Details Parent/Guardian Details
If you do not have a username and password, one will be created for you when you submit this form.
Client First Name: Mother's Name:
Client Last Name: Mother's Email Address:
Date of Birth: Mother's Mobile/Cell:
Gender: Father's Name:
Email Address: Father's Email Address:
Confirm Email Address: Father's Mobile/Cell:
Home Phone: Do you have any injury concerns?
Mobile/Cell:
Address 1:
Address 2: Do you have any medical conditions?
Suburb/Town:
State/Prov:
Zip/Postcode:
Sport (if applicable):

Training Dates: From 05-Feb-2018 To 13-Apr-2018

Training Days & Times:
Once a time slot is full you will be asked to make another choice.

Time Mon Tue Thu Fri
9:30 am
Clinical Pilates Equipment Class (Carolyn) (8 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
Clinical Pilates Equipment Class (Therese) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
Clinical Pilates Equipment Class (Therese) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
Clinical Pilates Equipment Class (Carolyn) (9 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
1:30 pm
Clinical Pilates Equipment Class (Therese) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
Clinical Pilates Equipment Class (Therese) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
4:00 pm
Clinical Pilates Equipment Class (Therese)(10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
4:15 pm
Clinical Pilates Equipment Class (Therese) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
FULL
5:30 pm
Gymstick Trio (Therese) (8 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
Clinical Pilates Equipment (50)/ Fascial Stretch (10) Combined (Therese) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
Clinical Pilates Equipment Class (Carolyn) (10 weeks)
Physiotherapy Posture & Pilates 48 Eaton Drive Eaton

DISCLAIMER:
I hereby agree to assume all risks and responsibilities surrounding my (or my child's) participation in the program under the instruction of Physiotherapy Posture & Pilates coaches. I understand that similar to all sporting activities, there is a risk of damage to personal property, injury or death which may result from causes beyond the control of, and without fault or negligence of Physiotherapy Posture & Pilates, its officers, agents, or employees, during the period of my (or my child's) participation. I understand completely the above agreement and agree to be bound thereby. By registering on our site you agree that we may send you email related to our facilities and programs. We will not provide your details to any other company.

Signed (Parent/Guardian): Date:        /         /        
Please note there is a 2% Merchant fee charged for transactions for Term fees paid for via eftpos or credit cards. We have other options available for payment to avoid this extra charge - direct deposit, cheque or cash
Payment Method:
Total Cost: $0.00
Promo Code:
Bank Transfer: Bank details will be provided on the next screen
Cash:

Please mail this form with a payment attached to: "Physiotherapy Posture & Pilates Pty Ltd, 48 Eaton Drive , Eaton WA 6232"