Physiotherapy Posture & Pilates

Physio Equipment Class Enrolment Form Term 3 2020 (10 Weeks)

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 20-Jul-2020 to 25-Sep-2020

Training Days & Times

Once a time slot is full you will be asked to make another choice.

Time	Mon	Tue	Thu	Fri
9:00 - 10:00 am	Physio Equipment Class (Carolyn) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL			Physio Equipment Class (Carolyn) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
9:30 - 10:30 am		Physio Equipment Class (Carolyn) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL	Physio Equipment Class (Carolyn) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL
10:15 - 11:15 am				Physio Equipment Class (Carolyn) Dependent on numbers Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL
1:30 - 2:30 pm		Physio Equipment Class (Therese) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL	Physio Equipment Class (Therese) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL
4:15 - 5:15 pm		Physio Equipment Class (Therese) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL	Physio Equipment Class (Carolyn) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL
4:30 - 5:30 pm	Physio Equipment Class (Therese) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton
5:30 - 6:30 pm		Physio Equipment Class (Therese) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL	Physio Equipment Class (Carolyn) Physiotherapy Posture & Pilates 48 Eaton Drive Eaton FULL

DISCLAIMER:
I understand and have read the class policy and acknowledge my responsibility if I cannot make a class that I must alert reception in the agreed time if I am to be offered a make up class option.

Agreement

Signed (Parent/Guardian)

Date

/ /

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

$300.00 10 week term fee 1 class per week paid by Week 1
$500.00 10 week term fee 2 classes per week paid by Week 1
$250.00 10 week term fee for one when 2 or more Family members enrol in class paid by Week 1
$32.00 Casual rate per session (Confirm dates with reception) (per session)
$0.00 Other option. Discuss with reception staff for pricing options

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

Term Fee enrollees payment must be made by Week 1

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