Form

Programme*

10-week Womens Wellness Programme 4-week Freedom from Dieting Programme

A $100 deposit is required at the time of registration, and goes towards the cost of the programme. This deposit guarantees you a place in the group. Please see end of form for payment details.

Balance due: 3 working days before programme starts.

Please note: There are only 14 places in each group .

Name*

Title First Name Last Name

Birth Date*

Month Day Year

E-mail

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone (W)

- Area Code Phone Number

Phone (H)

- Area Code Phone Number

Phone (M)

- Area Code Phone Number

Occupation

Workplace

Or Usual Occupation prior to retirement

Preferred start day*

Mondays 7pm Tuesdays 12.30pm Fridays 9.30am (this option is available for Freedom from Dieting programme).

If your 1st preference is unavailable, please indicate your 2nd preference*

Would you like an information sheet that you can give to your GP regarding your participation in the programme?

Yes No

Do you have any of the following conditions?

Please specify +

Please list prescription medications and reasons for taking them

What are your main reasons for participating in the programme?

CAUTION: In the 10-week Women's Wellness programme, one session includes yoga activities with a certified, experienced yoga instructor. Before doing yoga, please check with your doctor if you have any medical concerns.

Payment : * Please make cheques payable to "Mind-body Wellbeing" PO Box 6291, Dunedin 9059,
* or pay direct to bank account: 03 0883 0255508 00. Please enter your name under reference details.

Cancellation Policy: Cancellations prior to commencement of the programme will incur a cancellation fee: $40. Please note that no refunds are given after commencement of the programme.

Transfer Policy: If for any reason, you have doubts about being able to attend, transfers are accepted prior to commencement of the programme, and will incur an administration fee of $10 per person.

Costs: include GST. All costs are subject to change. Please check the website http://mindbodywellbeing.co.nz

Privacy Policy: Information is collected solely for the purposes of processing your application, booking or enquiry, keeping you informed of upcoming events, and assisting in providing programmes.

http://mindbodywellbeing.co.nz

Enter the letters as shown*

Either click 'submit form' below to email the form now, or click 'print form' and send to Mind-body Wellbeing PO Box 6291, Dunedin 9059

Mind-Body Wellbeing Registration Form