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Please complete this form if you woud like to book a space in a class Term 1 2012 commencing February 8

Name:
Email:
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Class Booking Into
Wednesday 7.30pm General Class commencing 8th February ($126/conc$112.50)
Wednesday 6pm Meditation and More commencing 8th February ($108/conc$95)
Please check any of the following that apply
High Blood Pressure
Low Blood Pressure
Back Problems
Neck Problems
Thyroid Conditions
Anxiety
Depression
Recent Surgery
Pregnancy
Other
For your safety and well being it is important that Kriya is informed of any physical/mental health issues
Specific Details of any of those above that have been checked
Other Health issues not covered above
What would you like to gain/experience from this class?
Is there anything you would like me to be aware of? Do you have any questions?
Payment Details: Prefered payment method is EFT transfer to Sucnorp Bank Account. Account Name: K Ponsford BSB: 484 799 Account Number: 600539350
EFT payment to bank account, please ensure you put your name in reference/description field so that payment can be identified
Cheque/Money order sent to 12 Poplar Grove Lawson NSW 2783
Payment in full (cheque or cash) in sealed envelope prior to start of first class.
Credit Card VIA Paypal, please go to online shop to complete transaction
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