Essentially Men Registration Form |
||
| First Name : | __________________________________________ | |
| Last Name : | __________________________________________ | |
| Preferred Name : | __________________________________________ | |
| Address : | __________________________________________ | |
| __________________________________________ | ||
| __________________________________________ | ||
| Phone - home : | __________________________________________ | |
| Phone - work : | __________________________________________ | |
| Email : | __________________________________________ | |
| Course Number : | __________________________________________ | |
| Occupation : | __________________________________________ | |
| Birthdate : | __________________________________________ | |
| Have you attended a group or had any counselling before? YES NO | ||
| Please give details : | __________________________________________ | |
| __________________________________________ | ||
| __________________________________________ | ||
| PLEASE REGISTER ME : | I enclose (make cheques payable to Essentially Men) : | |
| - $595 full payment (sliding scale to
$345) Those on lower incomes have the option of sliding down the scale. Payment plans and some subsidised places available. |
||
| - $50 deposit | ||
| FUTURE WORKSHOPS : | I am unable to make this date so please let me know of future workshops. | |
| PLEASE NOTE : | To secure your place on the course you must return your completed registration form and pay the course fee in full. Course registrations must be fully completed 48 hours prior to course commencement. We reserve the right to cancel this course at any time. | |
| SEND TO : | Essentially Men, 13 Maidstone Street, Ponsonby, Auckland New Zealand, +64 (9) 376 2386, |