WorkshopS Continuing The Journey Enrolment form This form is for our Mirboo North location. "*" indicates required fields Please choose the dates you would like to attend (each session is $75) Sunday 20th August 2023 Sunday 24th September 2023 Sunday 22nd October 2023 Sunday 19th November 2023 Sunday 20th August 2023 Price: Sunday 24th September 2023 Price: Sunday 22nd October 2023 Price: Sunday 19th November 2023 Price: Name* First Last Date of Birth* DD slash MM slash YYYY Gender* Male Female Other Address* Street Address City State / Province / Region ZIP / Postal Code Occupation Phone*Email address* Medical (Please tick if applies) Epilespy Diabetes Heart condition Anaphylaxsis Asthma Mobility support required Allergies (please list below) Other (please list below) Medical / Dietary requirementsEmergency Contact Name* Emergency Contact Phone Number* Have you experienced art therapy in the past? Yes No CommentsPaymentPayment in full required before course commences. Credit Card Details*Card Details Cardholder Name
