PERSONAL POWER DEVELOPMENT Registration Form

Please copy and paste this form into a Word Document so that you can complete it.  Please then print it out, sign it and post it to Personal Power Development, Old Castle, Llangain, Carmarthen SA33 5BD.

Name:

Address:

Telephone Number:

Email:

Skype:

Messenger:

Year of Birth:

Marital Status:

Children:

GENERAL CONCERNS:

WHAT YOU WOULD LIKE TO ADDRESS:

MEDICAL HISTORY (where relevant):

STRESS-RELATED/PSYCHOLOGICAL/EMOTIONAL HISTORY:

ISSUES:

DOMESTIC SITUATION:

HEALTH GENERALLY:

ARTIFICIAL AIDS e.g. Pacemaker:

MEDICATION & REASON FOR IT BEING PRESCRIBED

ALLERGIES

PHOBIAS OR FEARS:

DO YOU SUFFER FROM:  Migraine, Epilepsy, Heart Problems, Breathing Problems, Nervous Conditions, Othe

I enclose a cheque payable to Angela Timms or I have sent a payment via paypal to serenitywildhare@yahoo.com for my initial set up fee together with …………………….. as start up credit to pay for my one on one training.

Signed                                                                    Date                                Print Name

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