| Contact Details |
| Name: |
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| Address: |
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| Home Phone: |
(Inc. Area code) |
| Work Phone: |
(Inc. Area code) |
| Date of Birth: |
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| Occupation: |
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| E-mail: |
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Comments / Feedback |
Special dietary requirements:
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I am attending Heartworks Lomi Lomi 1 DATE:
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I am attending Heartworks Lomi Lomi level 2 DATE:
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I enclose
Being deposit ($100 non refundable) / full payment for the course
All cheques payable to 'HEARTWORKS LOMI LOMI' |
| I understand full payment is required before course commencement |
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yes
no |
| Do you have transport? |
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yes
no |
How did you hear about the course?
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| Method of payment: |
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Cheque
Money Order
Cash
Bank Transfer |
| I understand that the $100 deposit is non refundable: |
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yes
no |
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