Well Mother Course Booking Form

Course Title:	MASSAGE & PREGNANCY APNT DIPLOMA COURSE
Course Location:	BOYLE FAMILY LIFE CENTRE : (071) 966 3000
Course Dates:	THURS Ú SUNDAY on MARCH 29—APRIL 1^st, 2007
CPD POINTS:	Irish IMTA: 100 CPD points	EMBODY: 30 CPD credits

Your Name:
Mailing Address:
Your PHONE:	Your FAX:
Your Email / Web:

I do / do not give permission (delete as appropriate) for my contact details to be circulated to other course

participants. Please indicate any alterations required for circulation (e.g., no phone).

Cheque payable to “FAMILY LIFE CENTRE”

q Full Course Fee: 600 Euros. I would like to reserve _____ place/s.

q I enclose deposit of €200 per person. q Early Bird Discounted Fee: €550.

For each place…

q Full Course Fee Balance Due by Feb. 28^th, one month before start date. Manuals for

Massage & Pregnancy Course will only be posted upon receipt of full course fees.

Or:

q I apply for the Early Booking Discount and will pay the reduced Course Fee of €550 Euros To be received by Ruth Toal on/before Friday/February 9^th, 2007.

* All payments are non-refundable. A transfer is only possible provided a replacement can be arranged at least 1 week before the course commences. Transfer fee is €40 (if applied for 1 month before course commences) or €75 (if less than one month). Only one transfer is allowed. Well Mother will refund fees if cancellations occur on our side but is not liable for any expenses incurred by the participant associated with joining the course.

Occupation:

Qualifications:

Details of other experience/training in the holistic health field:

How did you hear about Well Mother? (1) Advert/leaflet, if so, where:

(2) Word of mouth/recommendation, if so who from and how do they know us?

(3) Other - please specify:

Do you have any condition/infection that is a contra-indication for massage/shiatsu?

Any other relevant information e.g. disabilities/allergies?

I declare that I am fit and healthy and over 18 years of age. I know of no reason why I should not attend this course.

I declare that the above information is correct and to the best of my knowledge. I agree to inform the Course Director of any change in my health, should I contract/develop a condition that is a contra-indication for massage / shiatsu.

I have read and agree to abide by the payment and cancellation policy *.

Signed ____________________________________ Date _____________

Post to: RUTH TOAL, ALTIQUIN, DRUMKEERIN, CO. LEITRIM.

**Please make a copy of this form, as no reminders will be sent**