Register for a workshop Workshop registration Which workshop are you are registering for:*"Filling my well" workshop"Filling my well" workshop for teenage girlsArt workshop for primary school studentsPre HSC Chill Wellbeing WorkshopArt workshop for adultsWorkshop date*Workshop attendee name* First Last Date of birth*Phone*Address* Street Address Address Line 2 City NSWNTACTQLDVICWASATAS State Postcode Email* Parent contact for workshop bookingParent name* First Last Parent contact phone*Parent email* Contact person in case of emergencyEmergency contact name*Emergency contact phone*Health questionsThe following questions refer to the workshop attendee:Are you on prescription medication?* Yes No Have you been to hospital recently?* Yes No Have you given birth in the last 6 months?* Yes No Are you pregnant?* Yes No Do you have any of the following? Gout Stroke Dizziness or Fainting Stomach ulcer Liver or Kidney Condition Glandular Fever Heart Murmur High Blood Pressure Palpitations or Pain in the Chest Raised Cholesterol Any heart condition Diabetes Epilepsy Hernia Rheumatic Fever Have you ever had or do you have? Arthritis Asthma Cramps Are you dieting or fasting? Do you smoke? Are there any other conditions which may be reason to modify your exercise program? Any pain or major injuries in the following areas Neck Back Shoulders Knees Ankles Any muscular pain? How would you describe your current level of exercising?LowModerateHighHow often do you currently exercise?Statement from attendeeI recognise that the instructor is not able to provide me with medical advice with regard to my medical fitness and that this information is used as a guideline to the limitations of my ability to exercise. I have answered the questions to the best of my ability.Acceptance statement* I understand the information and advice above Primary students sectionDoes your child have any illnesses, conditions or allergies that we need to be aware of? Please provide detailsEnrolment conditions The upmost care will be taken with your child during these classes. No responsibility is taken before or after the class Enrolment will be confirmed on payment In case of an emergency an ambulance will be phoned and the emergency contact person will be notified on the phone number provided Beautiful manners are to be used during these classes Enrolment conditions* I understand and agree to the enrolment conditions outlined above GeneralDo you have any food allergies or intolerances?* Yes No Please provide details of your food allergies/intolerances:How did you hear about this workshop? Facebook Instagram Website Email Friend Other Do you give permission for any images taken at the workshop to be used in advertising material for future workshops?YesNoAny questions?Any additional information or questions?CommentsThis field is for validation purposes and should be left unchanged.