Registration Form

Course Registered for:

Title:

Full Names and Surname:

Preferred Name:

Identity Number:

Gender:

Preferred Language:

Postal address:

Residential address:

Employment & position:

Mobile phone:

Work Number:

Fax:

Additional contact number:

Email address:

Professional registration (if applicable):

Please read the following agreement:

I agree to pay the workshop fees as indicated for the workshop registered for.
Payment arrangement:
1. Please note that the workshop fees must be paid in full prior to commencement of workshop.
2. If the workshop fees are not paid in accordance attendance of workshop is not allowed.
3. Also note that fees are non-refundable if the workshop is cancelled or not attended by the learner.
4. Funds are also not carried over for another workshop or similar workshop at a later stage.
Workshop material will be issued as determine by the presenter at the workshop accordingly.
I undertake to submit myself to the rules and regulations stipulated.
I hereby indicate my decision to register as a learner with the Vida Health and Wellness Centre (Training Division) for the workshop indicated in the application.

I have read and agree to the terms and conditions

This must be completed by the person responsible for the payment of the workshop fees:

Workshop registered for:

Workshop fees:

Declaration: I declare that the information supplied by me (the learner), is correct and true.

I confirm this declaration

Name of account holder: Vida Health & Wellness

Bank: ABSA

Account number: 406 127 1434

Branch code: 632 005

Proof of payment needs to be:

Reference: Name and surname

VIDA HEALTH & WELLNESS CENTRE