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:

Prerequisites for STOTT PILATES® courses:

Mat & Reformer - if you are unexperienced you need to attend our Functional Anatomy course. 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. (unless other arrangements have been made)

Advance courses - you need to complete the intensive course first.

ICCB - Cadillac, Chair & Barrels - you need to complete either IMP or IR first.

Workshops and Foundation Courses - Open to anyone wanting to experience the Merrithew™ world.

Functional Anatomy course - Prerequisite if you have no experience in the fields of fitness or movement.
Course selection please tick

FA - Functional Anatomy Course IMP - Intensive Mat Course IR - Intensive Reformer Course IBRL - Intensive Barrels Course ICHR - Intensive Chair Course ICAD - Intensive Cadillac Course 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 HALO Foundation Course Fascial Movement 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 Facebook Instagram Internet search Friend/colleague Other
- A 20% non-refundable deposit is required to secure your spot:
  - Use the PAYMENT AMOUNT box below to pay through PayPal
  - Or leave the payment block blank to do a direct transfer instead
  - Keola Wellness, BSB: 034-216, ACC NO: 372 001, REFERENCE: Your Name
- Workshops need to paid in full 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
I have included the following

20% non-refundable /non-transferable course fee deposit Full payment for Course Full payment for workshop Full payment for Course Material
Cancellation policy: If the student cancels their workshop or course enrollment less than 4 weeks prior to the start date of the workshop or course, there will be no refund of monies paid. Where the student cancels their enrollment with greater than 4 weeks notice the 20% deposit will be forfeited toward the cancellation fee.
I hereby agree:

I plan to attend all course hours I certify that the information provided on this application is accurate I understand that failure to provide accurate information may result in my removal from the certification program
Should be Empty: