| Surname |
______________________________________________________________ |
| Given Names |
______________________________________________________________ |
| Date of Birth |
______________________________________________________________ |
| Address |
______________________________________________________________ |
| City |
________________________ |
State
______________________ |
| Postcode |
________________________ |
Country ____________________ |
| Phone Number |
________________________ |
Fax _______________________ |
| Email address |
______________________________________________________________ |
| Please
nominate dates of course you wish to attend |
| _____________________________________________________________________________ |
| Person to contact
in case of emergency or delayed arrival or delayed return: |
| Name |
______________________________________________________________ |
| Address |
______________________________________________________________ |
| City |
________________________ |
State_______________________ |
| Postcode |
________________________ |
Country ____________________ |
| Phone (Home) |
________________________ |
Fax:_______________________ |
| Phone (Work) |
________________________ |
Mobile :____________________ |
| Do you suffer from
any illness? ____________________________________________________ |
Do you have any special dietary requirements? If
yes detail what foods you cannot eat and what foods you
prefer |
| ____________________________________________________________________________ |
| What is your level of fitness? ____________________________________________________________ |
