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.
Year of Birth:
WHAT YOU WOULD LIKE TO ADDRESS:
MEDICAL HISTORY (where relevant):
ARTIFICIAL AIDS e.g. Pacemaker:
MEDICATION & REASON FOR IT BEING PRESCRIBED
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 firstname.lastname@example.org for my initial set up fee together with …………………….. as start up credit to pay for my one on one training.
Signed Date Print Name