NB: Feel free to correct any automatically-filled details below
FIELDS MARKED * ARE MANDATORY
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  About your Course    
1.  Course Name:  
2. Course Date: /  
       
  About you    
3.  Title:  
4. First Name:  
5. Surname:  
6. Full Name (As it will appear on your certificates where applicable):  
7. * Date of Birth:  
8. Email Address:  
9. Address Line 1:  
10. Address Line 2:  
11. Address Line 3:  
12. City:  
13. County:  
14. Country  
15.  Postcode/zipcode (if applicable)  
16. Daytime telephone:  
17. Evening telephone:  
  Leave blank if it is the same as the Daytime number    
18.  Occupation:  
18.a  Company Name:  
19. Previous NLP experience (if any):  
       
  Questions about your Health    
20. * Are you in good physical health?    
  Do you suffer from or have you ever suffered from the following?  
21. * Asthma or bronchitis  
22. * Clinical depression  
23. * Epilepsy  
24. * Heart condition  
25. * Are you taking any prescribed medications?  
26. * If Yes, please give details here including dosage:  
27. * Have you ever been under a doctor's care for a psychiatric condition?  
28. * Do you suffer from any physical disability or psychological condition that could prevent full participation in an active study programme?  

 

Declaration

I understand that the training I receive is for educational purposes only and that it is not a substitute for proper medical or psychological treatment. If I suspect or know that I am suffering from any physical or psychological ailment or condition, then I will seek appropriate medical or psychological treatment before attending GOODMAN-BLAKE Training.

I understand that no personal tape recording will be permitted during the training. I understand that, in the interests of security and the comfort of the training group as a whole, GOODMAN-BLAKE reserves the right to deny any individuals access to registration, the training event in its entirety, or any part of the training without prior notification or explanation.

I have read the application and declaration, truthfully completed all relevant portions and I understand and agree to all terms.