Please submit the following details & we will be in touch with you soon :)
PERSONAL DETAILS:
Company Name (if applicable)
First Name:
Last Name:
Preferred Name:
Email Address:
Phone Number:
Birth Date:
Marital Status:
Number of Children:
Occupation:
Street Address:
Suburb:
State:
Postal Code:
Country:
HEALTH & DIETARY:
Do you have any allergies?*
Do you have any mobility issues?
*We will provide healthy lunches each day of the course, plus morning and afternoon tea and will cater for any allergies. However if you have any food preferences or intolerances (eg; no wheat, no sugar, etc), please ensure you to bring your own snacks for morning and afternoon tea.
COURSE DETAILS
Which course date would you like to attend?
How will you be arriving?
If known, where will you be staying when attending the course?
MEDICAL & EMERGENCY CONTACT DETAILS:
Full name of your emergency contact:
Relationship to you:
Emergency Contact Phone:
Alternative Emergency Contact Phone:
Have you had any major operations?
Do you, or have you ever had any major illnesses or diseases?
Have you ever been diagnosed with mental illness?
If you have been previously diagnosed with mental illness, how do you compare your mental state now in comparison to time of diagnosis?
Are you on a mental health plan?
Do you take any regular medications?
By proceeding, you consent to us collecting your personal information in accordance with our Privacy Policy
*  we will not spam, rent, sell or disclose your information to anyone *