Course/Workshop Application Form

Course/Workshop Application Form
Name *

First Name Middle Name Last Name
E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
Please note: We have prerequisites for all of our STOTT PILATES courses. - Foundation & Functional Anatomy courses are open to all.- The STOTT PILATES Intensive Programs are intended for those already working in the fields of fitness or movement, or those who have completed the Functional Anatomy course- To attend a advance course you need to complete the intensive course first.- To attend ICCB you need to complete IMP or IR first.
Course selection please tick

Functional Anatomy Course IMP - Intensive Mat Course IR - Intensive Reformer Course ICB - Intensive Chair & Barrels Course IC - Intensive Cadillac ISP - Injuries & Special Population Course AM - Advance Mat Course AR - Advance Refomrer Course ACCB - Advance Cadillac, Chair & Barrels Course Total Barre Foundation Course Core Foundation Course ZENGA Foundation Course - Mat ZENGA Foundation Course - Equipment Other
Workshops:
Please name & number the workshops clearly (one line per workshop)
Relevant Education
*Anatomy component of education completed where & when
Relevant Experience
*Teaching experience & your own pilates experience (when, where & what method)
Personal info
Do you have any injuries, conditions or postural issues? Are you currently pregnant or recently given birth? Failure to disclose any issues prior to enrolment may result in your removal from the course!
How did you hear about us? *

Website Friend/colleague Internet search Other
- A 25% non-refundable deposit of the course fee is to be paid to secure your spot:
  - Keola Wellness, BSB: 034-216, ACC NO: 372 001, REFERENCE: Your Name
  - Or use the link below to pay through PayPal
- If you are attending workshops you need to pay in full the amount due to secure your spot.
- No spaces will be kept without a deposit for courses or payment in full for workshops
- You may only apply discounts if you pay by the required date to receive a discount.
- Once we receive your submission and payment we will confirm your placement. Should you not meet or cannot achieve the minimum requirements a refund will be made.
Payment Amount

AUD Total fee
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