Intimacy Masterclass

Full Name (Male)

First NameLast Name

Full Name (Female)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Email

example@example.com

Workshop Date

Select Type of booking

Payment:

Please deposit funds into the following account:

Westpac
BSB 035-075
Account number: 367878
Account Name: KaizenPeace
Reference: (your name)

It would be appreciated if you send us an email if you do a direct debit to confirm your deposit.

Please sign below after reading the Cancellation Policy - link below.

Cancellation Policy (opens in a new window)

If you have any questions please email Diane on diane@bto.net.au

Name preferred for name tag 1

Name preferred for name tag 2

Please sign below to confirm you have read and agree to the Cancellation Policy (opens new tab)

Signature