FMA Enrolment Form
Hosted by
Personal Details
Name:
Age:
Contact Number:
Email:
Occupation:
Which program level are you registering for (Please highlight)
Pathway 1
Pathway 2
Pathway 3
Pathway 4
Emergency & Medical Details
Emergency Contact Person:
Contact Number:
Relationship:
Terms & Conditions
There are no refunds available once the payment has been processed. If you
are unable to attend the session you have paid for, you can arrange to go to
another workshop (72 hours notice is required)
PAR-Q
Please highlight Y or N to the following questions:
1. Has your doctor ever said that you have a heart condition and that you
should only do physical activity recommended by a doctor?
Y
N
2. Do you feel pain in your chest when you do physical activity?
Y
N
FMA Enrolment Form
Hosted by
3. In the past month, have you had chest pain when you were not doing
physical activity?
Y
N
4. Do you lose your balance because of dizziness or do you ever lose
consciousness?
Y
N
5. Do you have any bone or joint problems (ie. back, knee or hip) that could
be made worse by a change in your physical activity?
Y
N
6. Is your doctor currently prescribing drugs (ie. water pills) for your blood
pressure or heart condition?
Y
N
7. Do you know of any other reason why you should not do physical activity?
Y
N
I hereby declare the above to be true of my current physical health status.
Should this status change, I understand it is my responsibility to inform the
staff of FMA.
By typing in my name and the date below, I am agreeing to the terms and
conditions outlined on the front page.
Name:
Date:
FMA Enrolment Form
Hosted by
Payment Details
Please highlight one of the payment options below:
Pay in full
2-month payment plan (Available for Pathway 1, 2 & 4)
4-month payment plan (Available for Pathway 1 & 2)
6-month payment plan (Available for Pathway 1)
Please note: Each course needs to be paid in full before class commences
Please highlight your preferred payment method:
Credit Card
Visa
MasterCard
By typing in my name and the date below, I am giving authorization to charge
my credit card
Cardholders Name:
Card Number:
Expiry:
CVC (Found on the back of your credit card):
Bank Transfer
PLEASE PUT JSSP IN PAYMENT DETAILS:
If you chose to pay via bank transfer, please email admin@e2edu.com.au
once payment has been made.
Payment is required 72 hours after your enrolment has been filled in.
Name: FMA
BSB: 033 048
Account number: 475647