Booking Form


Please note that all fields followed by an asterisk must be filled in.
First Name* First Name*
Last Name* Last Name*
E-mail Address* E-mail Address*
Street Address* Street Address*
City* City*
State/Prov* State/Prov*
Zip/Postal Code* Zip/Postal Code*
Home Phone* Home Phone*
Brain Gym
Touch of Health
Wellness Kinesiology
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Accommodation details
Payment details* Payment details*
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Booking Form
Print this booking form out and send together with your payment to the address below.

Payment Details
Once the �50 deposit is paid, the balance is due 2 weeks prior to the start of the course.

Post booking form and deposit to:-
Irene Lock,
4, Forest Gardens,
Waltham Chase,
Southampton, SO32 2LB

Cheques payable to Irene Lock please

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