Your Details

Name:

Address:

Telephone No:

Email Address:

Medical Information: Please give details of any medical conditions you have (including any history of mental illness):

Where did you hear about the Slimming Workshop?

Are you happy to receive information about any future events we hold? (we will never pass on your details to anybody else)

                                                            Yes      □

                                                            No        □

Workshop Date

Please Specify Date:
Saturday May 19th 2007 - 10:00am - 1:00pm    □ (Venue Lynsted)

Payment

Please make cheques / postal orders for £35.00 payable to:  M Tillman and send together with this application form to:

                                                M. Tillman

                                                Life Clinics

                                                69 Ospringe Road

                                                Faversham

                                                Kent. ME13 7LG

For credit / debit card payments, please phone us on 08456 038 052