Pilates/Yoga
Enrolment Card
(Please write in BLOCK CAPITALS)

Call prior to sending registration form to confirm if there is availability in your desired class.

Print form and return with full payment or €30 deposit balance due on first day (before commencement of classes) to:

DEIRDRE SOUCHERE
35 Orpen Rise, Stillorgan Grove, Stillorgan, Co Dublin

Name:

  
Address:  
Telephone:  
Mobile:  
Email:  
Please indicate which class you are attending Pilates
 
Day and time of class________________		 Yoga
 

Day and time of class________________
Start Date:
Method of payment:
Cash
 
Cheque
 
Amount paid:		  

Medical Screening - Confidential.
I understand that the advice & instruction given in the class is on the basis that I am in good health except insofar as that I have listed below any medical conditions from which I currently suffer or for which I have recently undergone treatment. Please include in the above any of the following, or any other condition which may be relevant: Pregnancy, arthritis, back pain, asthma, headaches, diabetes, epilepsy, heart conditions, high blood pressure, hernia, ulcers, bowel/digestive disorders, pneumothorax.

 

 

 
Signed: Date: