Form 01 @ Rehability

Pilates Enrolment Form

Personal Information

First Name:

Last Name:

Date of Birth:

dd/mm/yyyy

Address Line 1:

Address Line 2:

Suburb:

Post Code:

State:

Contact Phone:

Fax:

Email Address:

Health Fund Information

Health Fund:

Do you require a receipt?:

Yes No

Class or Classes you wish to enrol in

Select Location:

Select Term:

Select Class:

Select Day or Days:

Monday Tuesday Wednesday Thursday Friday Saturday

Select Time or Times:

8.00am 9.30am 5.15pm 5.30pm 6.30pm 7.00pm

How did you hear about our classes?

Any other types of classes or timeslots you would like to see introduced?

Method of Payment

Direct deposits can be made via
Internet Banking to
BSB: 802 404
Account Number: 42153835
Account Name: Rehability

Cheques can be sent to
Rehability
PO Box 141
Port Kembla NSW 2505

Payment needs to be made 2
weeks prior to term commencement

Please ensure all information is correct before clicking the submit button: