| Your full name: |
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| Your address: |
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| Postcode: |
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| Email: |
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| Contact number: |
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| Which course are you applying for? |
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| Dates of the course? |
Start date:
Finish date:
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| What are your main reasons for taking the course? |
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| I am paying: |
The deposit
The full amount for the course
The full amount (concessionary rate) |
| I am paying by:
(Note - if you want to post a cheque to us, then please print out the form by clicking the link on the course page and send it to us with your cheque)
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Online payment
Telephone
Bank transfer
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act up's health assessment
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| I am: |
Male
Female
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| Are you presently taking medication or receiving treatment of any kind? |
Yes
No |
| If yes, please give details: |
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| Do you have any current or past injuries, however minor, which might effect your ability to undertake some exercises? Please give details: |
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| Please give details of any other personal or medical history of which we should be aware: |
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| Please give details of any allergies you might have of which we should be aware |
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| Do you have any disabilities or additional learning needs (including dyslexia) which you feel should be taken into consideration? We ask this so that appropriate adjustments can be made. |
Yes
No
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| If so, please give details: |
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| I confirm that I have read and agree with act up's Terms and Conditions. |
