Aikido / Qi Gong Workshop Registration Form

Please fill out required information, and mail, e-mail or fax with payement information to:

Fredericton Wellness Clinic

186 Lincoln Road, Fredericton, NB

E3B 2A3

E-Mail: WellnessClinic@nb.aibn.com

Tel: 506-452-9795

Fax: 506-451-9118

First Name:___________________________

Last Name: ___________________________

Date of Birth: Year______  Month______  Day_____ 

E-mail: ___________________________

Address: __________________________

City/Town: _________________________

Postal / ZIP Code: ___________________

Work Tel: ______________ Home Tel: _______________

Name of Workshop: _____________________________ 

Workshop Dates: ________________________

We accept payment by cheque, Master Card, Visa or American Express.

Print Name on Card: _____________________________

Card Type: ____________________________________

Card Number: __________________________________

Expirary Date:       Month: _______   Year: __________

Disclaimer: The Fredericton Aikido Dojo (Gym), Wellness Clinic and Qi Gong / Tai Chi Studio, its owners, instructors and students will not be held responsible by you or by any person acting on your behalf for any injuries incurred during the practice Aikido, Qi Gong, Yoga or Tai Chi at our facilities at 186 Lincoln Road, Fredericton, NB.  Please inform the instructor before the start of the workshop of any physical or other problem you may suffer from that may put you or fellow students in danger of infection or physical injury.

Partial refund available for workshops if requested two weeks prior workshop start date.

___________________________                       ____________________

Signature                                                                   Date

(If under 18 signature of parent or guardian)