Mums & Tums Booking Enrolment Form

TRINITY Mums & Tums

Antenatal & Active Birth Program
Bookings Essential - Classes Availability:

SOMERVILLE - Monday 19th February 2018 7:30pm - 9pm

OFFICER - Wednesday 21st February 2018 7:30pm - 9pm
Mum to be*

First NameLast Name
DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail Address*
Mobile Number*
Expected Due Date*

MonthDayYear
Date
Medical Details / Allergies / Pregnancy Issues
Current Medication
Name of Doctor
Doctor's Phone Number

Area CodePhone Number
Emergency Contact

First NameLast Name
Emergency Number
How did you hear about this program?
Other, please specify
PAYMENT DETAILS:

Must be paid in order for enrollment to be confirmed

Bank Deposit Details: A/C name: D M Ogden BSB: 633 000 A/C Number: 158004077

Please use your name as the reference.
FOR DIRECT DEPOSIT PAYMENT ONLY

SOMERVILLE - EARLY BIRD PRICE (Prior to 5th Feb 2018) $180SOMERVILLE - $210OFFICER - EARLY BIRD PRICE (Prior to 5th Feb 2018) $180OFFICER - $210

FOR CREDIT CARD PAYMENT ONLY

SOMERVILLE - EARLY BIRD PRICE if booked before 5th Feb 2018$180.00AUD

SOMERVILLE - if booked after 6th Feb 2018$210.00AUD

OFFICER - EARLY BIRD PRICE if booked before 5th Feb 2018$180.00AUD

OFFICER - if booked after 6th Feb 2018$210.00AUD

Photo / Video consent for advertising & promotions

I DO give permissionI DO NOT give permission
I have read and agree to the Booking Terms & Conditions *

Yes
Signature

Clear
Date
Name

First NameLast Name
Phone: 0437 331 308
www.trinityhealing.com.au
trinityreikiandhealing@gmail.com
Should be Empty: