Maple Arts Patient Enrolment Form
Client Information
Center Name:
*
Synapse Mustard
Synapse Azalea
The Oleaster
Olive Prime Peridot
Patient Full Name:
*
Email
example@example.com
Patients Phone Number:
Please tick the services the patient enrolled for:
Art Therapy
Room & Board Plan
Teaser Package N 20,000
1 Month Mustard Package N 30,000
1 Month Package + Painting Kit N 45,000
1 Month Top-up (Existing Subscription) N 37,000
2 Months Package + Painting Kit N 78,000
3 Months Package + Painting Kit N 110,000
None
Art Therapy: Tie & Dye
2 Month Package + T-Shirt N 5,000
1 Month Package + Brocade Material N 25,000
1 Month Package + T-Shirt N 30,000
2 Month Package + Brocade Material N 45,000
3 Month Package + Brocade Material N 65,000
3 Month Package + T-Shirt N 80,000
None
Dance Therapy: Dance & Movement
1 Month Package N 20,000
1 Month Package + Yoga Mat or Fitness Kit N 25,000
1 Month Package + Yoga Mat + Fitness Kit N 32,800
None
Start Date
*
-
Day
-
Month
Year
Date
Admin Name
*
Admin Email
*
example@example.com
Submit
Should be Empty: