Vision Exercise Physiology

Client 1

Client Details

Client First Name

Client Last Name

Date of Birth

Gender

Email Address

Confirm Email Address

Create your password

Enter the password that you would like to use for your new account.

Confirm your password

Home Phone

Mobile/Cell

Parent/Guardian Details

Mother's Name

Mother's Email Address

Mother's Mobile/Cell

Father's Name

Father's Email Address

Father's Mobile/Cell

Address

Address 1

Address 2

Suburb/Town

State/Prov

Zip/Postcode

Health and Fitness

Do you have any injury concerns?

Do you have any medical conditions?

Training Dates

Training Days & Times

Agreement

Payment Method

There are no refunds for any enrolments into Vision Exercise Physiology related programs. When you sign/tick confirmation for this enrolment you are acknowledging that you know this as a fact and have accepted it as a condition.

Please mail this form with a payment attached to: "Vision Exercise Physiology, 324 Hume Street, Toowoomba QLD 4350"

				Tue	Fri
5:00 pm	U/14 & U/12	55-57 Kitchener Street, Toowoomba	$50
5:30 pm	U/18 & U/16	55-57 Kitchener Street, Toowoomba	$50

Toowoomba Basketball Strength and Conditioning Term 3