Application for Student Enrolment

Fill out the form below or download the pdf version below and email to info@goldenphoenixtaichi.com

Download PDF Enrolment Form

Student Enrolment

Given Name *

Family Name *

Gender *

Male

Female

Date of Birth *

Email Address *

Address *

Suburb *

Postcode *

Telephone *

Home

Business Phone

Business

Mobile Phone

Mobile

Profession *

Skill

Hobby

Emergency Contact *

Name

Emergency Email *

Email

Medical Information

Please select any pre-existing medical conditions

Heart/Cardiovascular Disease

Asthma/Breathing Disorders

Diabetes

Orthopedic Concerns

Psychological Problems

OtherOther

Blood type if known

Previous Martial Arts Experience

Martial Tai Chi Chuan

Tai Chi for Health

OtherOther

I hereby give permission for photographs/images of myself to be used on: www.jmhconsultau.com.au, Facebook Julie M Hutchin Goldenphoenix Taichi, Facebok Julie M Hutchin Consulting Australia, Google+, LinkedIn, Spiritualnetworks.com, Google Bloggers, Connect Magazine *

Yes

No

Allow me to inspect the images first

Waiver & Release Form *

Acknowledgement Waiver & Release from Liability

Read carefully and check. Read Waiver

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