The Book of Purification Course
Student Enrolment to be completed by a parent/guardian aged 18 and over.
Have you previously attended YMA Weekend School?
*
Yes
No
Student Information
Personal information about the Student enrolling.
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Mobile Number
*
Student mobile number (Or the best contactable mobile number that may be added to the Student Whatsapp group setup for this course).
E-mail
*
Student Email Address
Name of academic School/University
*
School Class/ University Year
*
Year currently undertaking in 2018
Medical Conditions
It is essential that staff are aware of any medical conditions your child may have to best cater for them.
Do you have any diagnosed Medical conditions?
*
Do you have any special dietary requirements?
Medicare Number
*
Emergency Contact
Information about a parent/guardian/next of kin for the student (must be aged 18 years and older)
Name
*
First Name
Last Name
Relationship to student
*
Mobile Number
*
Phone Number
-
Area Code
Phone Number
E-mail
Address
*
Street Address
Street Address Line 2
Suburb
State
Postcode
Photography & Film Permission
For purposes of documentation, marketing, and evaluation, it is necessary to take photos/videos of students. Images may be used for printed publicity, online and social media activities. We will not use the student's image without your consent.
Photography & Filming Permission
*
I give photo / film consent
I do not give photo/film consent
Declaration
By ticking the box below you are agreeing that the above information is correct and you will inform YMA Weekend School of any changes to details.
To be completed by a parent / legal guardian.
*
I agree that the above information is correct.
Fees
Payment of fees is a requirement to secure your enrolment.
Please choose from one of the following payment options
*
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Course fee
$
85.00
AUD
Total
$
0.00
AUD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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