Course Registration Form

Workshops & Courses Registration Form

* Indicates required field

Name *

First

Last

Gender *

Age *

Phone Number *

Email *

Address *

City *

Country *

Postcode *

How long have you been practising yoga? *

Please provide brief details of any medical conditions you have eg. include allergies, medications, psychiatric treatment, nervous disorder etc. Please advise if you are pregnant. If none please enter "None" *

Emergency Contact Name *

First

Last

Emergency Phone Number *

Please select the type of course and price: *

Please specify the starting date of the course or workshop: *

Payments can be done as a direct bank transfer. Bank details are available at the end of this form. Full payment is required to secure a booking. Cancellations 2 weeks prior to start date, full refund less $50, no refund anytime after. *

Yes I Agree

How did you hear about the course? *

If Other please specify: *

Would you like to receive our monthly eNewsletter to keep up to date with what's happening, yoga tips, recipes and more? *

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BANK DETAILS FOR A DEPOSIT OR TRANSFER

Payment can be done as a bank deposit or transfer to the following bank account:
Bank Transfer
Bank: NAB (National Australian Bank)
Account Name: Juan Pineros
Account: Savings
BSB Number: 082 - 332
Account Number: 13 - 451 - 0575
Reference: Your Name

Please send an email confirmation to info@yogawhitelotus.com once the payment is done.

www.yogawhitelotus.com / yogawhitelotus@gmail.com / +61 (0) 477 943 697 or (0) 403 838 750

Workshops & Courses Registration Form

BANK DETAILS FOR A DEPOSIT OR TRANSFER

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