Section 1 - Your Details

Title______________

Surname____________________________________________________________

First Name__________________________________________________________

Address____________________________________________________________

City_______________________________________________________________

Post Code__________________________________________________________

County_____________________________________________________________

Telephone___________________________________________________________

Mobile______________________________________________________________

Email_______________________________________________________________

Section 2 - Course Requested

Practical Or Shorebased________________________________________________

Course Date_________________________________________________________

Course Required ______________________________________________________

Section 3 - Health Declaration

Details Of Any Medical Treatment Being Recived (If None Please Write None)

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Declare That To The Best Of My Knowledge, I Do Not Suffer From Any Of The Following Medical Conditions:
(Please Tick "YES" To Indicate If You Do Suffer From One Or More Of The Conditions Listed)

Epilepsy: Yes No

Disability: Yes No

Giddy Spells: Yes No

Asthma: Yes No

Diabetes: Yes No

Angina: Yes No

Other Heart Condition: Yes No

Section 5 - Terms & Conditions

A £100 deposit will be required per person, to confirm booking.

Booking Conditions: If through circumstances beyond our control the school is unable to carry out any booking then all deposits and fees will be refunded and the Schools liabilities thereafter cease. Pupils are responsible for the payment of the balance of the fee two weeks prior to the course commencement date.

In the event of cancellation by the client at any time prior to the course, the School reserves the right to retain deposits or fees paid. Every effort will be made to fill the cancelled booking in which case a refund will be made less expenses incurred, if any.

I have read and understand the terms and conditions set out above: Yes No

Please Send This Information To The Address Provided:

FASTACK
62 Castle Road
Cottingham
East Yorkshire
HU16 5JG