Booking/Enrollment Form

Please tick course/ or enter workshop title

Workshop Title: …............................................................................................................ (please enclose cheque/or pay by BACS deposit of £20 to secure your place)

Name:_____________________________________________________________________

Address:___________________________________________________________________

__________________________________________________________________________

Post Code:__________________________________________________________________

Telephone Number:___________________________________________________________

Mobile Number:_____________________________________________________________

Email:_____________________________________________________________________

Date of Birth:_______________________________________________________________

Are you in good health:_______________________________________________________

 _____________________________________________________________________________________________________________________________________________________________

Please return this form with your appropriate deposit to secure your place

Cheques made payable to: Jacqui Bastock


Correspondence address:

Celtic Quiet

The Natural Health Service

Pagefield House

2 Page Street

Swansea SA1 4EZ

 

You can also pay by BACS

J.A. Bastock

Sort Code: 09-01-36

Account Number: 40739784


 Thank you for completing this booking form

I look forward to meeting you.

Signature________________________________________      

Date:_____________________