ENROLMENT FORM
Introductory Course
Tuesday 13th March 2018 - Wednesday 14th March 2018
(Please complete in block capitals)
First name: ______
Surname: ______
Address: (please give either your home or work address, whichever is best for correspondence)
______
______
______Postcode: ______
Tel: (Mobile) ______Tel: (Alternative) ______
Email Address: ______
Discipline: ______(PT, OT, SLT, Dr, etc.)
How did you find out about this course? ______
Course Fee: £375.00
I enclose payment or please invoice my employer, details below
Contact name: ______
Organisation: ______
Address: ______
______
______Postcode: ______
Please make cheques payable to: Bobath Children’s Therapy Centre Wales
Please return to:
Bobath Children’s Therapy Centre Wales
19 Park Road
Whitchurch
Cardiff
CF14 7BP
Upon receipt of payment we will send you a receipt and confirmation of your place.
Should you have any queries or questions, please do not hesitate to contact Niccy on (029) 2052 2600.