Bronze Pack Enrolment Form - Human Performance Centre

Select Advanced Nutrition Level I date

OR select Advanced Nutrition Level II date

2 – 3 March 2019
To be confirmed

Select Female Specific Training date*

Name*

First Last

Date of Birth*

Phone*

Email*

Preferred method of contact?*

Phone (during business hours)
Phone (outside business hours)
SMS
Email

Do you have any disabilities that may impact your ability to study?*

Yes
No

If yes - please download medical clearance from here download medical clearance. Please fully complete THIS FORM and have it signed by a Doctor and emailed to info@h-p-c.com.au PRIOR to course commencement.

If yes, please provide details below:

Do you have any medical conditions or injuries that may impact you from participating in exercise?*

Yes
No

If yes - please download medical clearance from here download medical clearance. Please fully complete THIS FORM and have it signed by a Doctor and emailed to info@h-p-c.com.au PRIOR to course commencement.

If yes, please provide details below:

Are you pregnant?*

Yes
No

If yes - please download medical clearance from here download medical clearance. Please fully complete THIS FORM and have it signed by a Doctor and emailed to info@h-p-c.com.au PRIOR to course commencement.

Gender*

Male
Female

Emergency / Next of Kin Contact

First Person

Name*

First Last

Phone*

Relationship to you*

Second Contact Person

Name*

First Last

Phone*

Relationship to you*

Your Residential Address*

Street Address Suburb State Postcode Country

ID File Uploader (10MB Limit) Page 1 (ID is required for student record identity purposes)*

ID File Uploader (10MB Limit) Page 2 (optional)

Of the following categories, which best describes your current employment status?*

Full-time Employee
Part-time employee
Employed – unpaid worker in a family business
Self-employed – not employing others
Unemployed – seeking part-time work
Unemployed – seeking full-time work
Not employed – not seeking employment

Of the following categories, which best describes your main reason for undertaking this course?*

Within the last two years, have you regularly attended a gym/training facility or undertaken structured physical activity, twice per week?*

Yes
No

How did you hear about us?*

Notes/Comments

I have read and understood the contents of the HPC student handbook*

Yes

I have read and understood all Terms and Conditions associated with enrolment*

Yes

Payment Method*