Physiotherapy Posture & Pilates

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)

Dates

Days & Times

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

Payment Method

There are no refunds for any enrolments into Physiotherapy Posture & Pilates related programs. When you sign/tick confirmation for this enrolment you are acknowledging that you know this as a fact and have accepted it as a condition.

Cost

$180.00 Class Term Fee for 9 Weeks
$0.00 Other Please contact Reception
$25.00 Per week session Casual (per session)
$0.00 SWAS Approved Athlete

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

				Mon
4:15 pm	Balance in Sport	Physiotherapy Posture & Pilates 48 Eaton Drive Eaton

Balance in Sport Term 3, 2019 (9 weeks)