Physiotherapy Posture & Pilates

Term 1 2018 Adult

Client 1

Client Details

Client First Name

Client Last Name

Date of Birth

Gender

Email Address

Confirm Email Address

Create your password

Enter the password that you would like to use for your new account.

Confirm your password

Home Phone

Mobile/Cell

Parent/Guardian Details

Mother's Name

Mother's Email Address

Mother's Mobile/Cell

Father's Name

Father's Email Address

Father's Mobile/Cell

Address

Address 1

Address 2

Suburb/Town

State/Prov

Zip/Postcode

Health and Fitness

Do you have any injury concerns?

Do you have any medical conditions?

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.

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.

Agreement

Signed (Parent/Guardian)

Date

/ /

Payment Method

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

Cost Per Person

$0.00

Total Cost

Group Discount

Promo Code

Promo Code Discount

Grand Total

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"

Time	Mon	Tue	Thu	Fri
9:30 - 10:30 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 - 2:30 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 - 5:00 pm			Clinical Pilates Equipment Class (Therese)(10 weeks) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
4:15 - 5:15 pm		Clinical Pilates Equipment Class (Therese) (10 weeks) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL
5:30 - 6:30 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