Activity Registration Form

Activity Registration Form

Please note that completion of the headings with an asterisk is compulsory. The form cannot be submitted before these fields are completed.
Name*

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Emergency Contact Name

First NameLast Name
Relationship to you
Phone Number
Please enter a valid phone number.
Are you accompanied by a carer?

YesNo
Carer's Name / Agency
Contact Details
Are you a financial member of Coolum HeARTS inc?*

YesNo
Fees per session:

Members - $10

Non-members - $20

Carers - $10

The carer fee entitles the carer to participate in the session as well as the client.
How will you be paying per term?*

CasualFull amount up front
Which activities would you like to register for? (Please tick the relevant box and refer to the What’s On Program for fees and direct debit information.)

Art Monday 9:30 to 11:30Choir Monday 10:30 to 12 NoonMeditation Wednesday 10:00 to 11:00Ukulele Wednesday Beginners 11:30 to 1:00 Intermediate 1:30 to 2:30pmMen's Resilience Wednesday fortnightly with JohnMosaics Thursday 9:30 to 12:30Gentle Yoga Friday 9:30 to 10:30Heartbeats Djembe Drumming Friday 10:30 to 12 Noon
Should be Empty: