Enrolment Form Online Program
Content
Enrolment Form
Online Program- $200 inc GST
Childs First Name………………………………………………… Surname……………………………………………………
Childs D.O.B…………………………………………………………………..
Parents First Names……………………………………………..Surname……………………………………………………
Address…………………………………………………………………………………………………………………………………….
…………………………………………………State…………………………………………..Postcode………………………….
Telephone Home………………………………………………………………
Childs Mobile (if applicable)……………………………………………...
Parents mobile…………………………………………………………………..
Email………………………………………………………………………………………………………………………………………….
Once enrolment form is received and confirmed, an invoice shall be email with payment and
delivery of program details.
Please either print and post form to: Self Esteem Co. U706 Points North Apartments 38-44 Queen
St Kings Beach QLD 4551 or Scan and email to [email protected]
Prelimenary Questions.
What has prompted you to enrol your daughter in an online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
What results are you wanting for her from the online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
What time is able to devoted by your daughter for the online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
Is your daughter in aggreance with doing the online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
What is your main self esteem concern for your daughter?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
Please use this space to to add any additional information you would like Janis (Coach) to know.
Online Program- $200 inc GST
Childs First Name………………………………………………… Surname……………………………………………………
Childs D.O.B…………………………………………………………………..
Parents First Names……………………………………………..Surname……………………………………………………
Address…………………………………………………………………………………………………………………………………….
…………………………………………………State…………………………………………..Postcode………………………….
Telephone Home………………………………………………………………
Childs Mobile (if applicable)……………………………………………...
Parents mobile…………………………………………………………………..
Email………………………………………………………………………………………………………………………………………….
Once enrolment form is received and confirmed, an invoice shall be email with payment and
delivery of program details.
Please either print and post form to: Self Esteem Co. U706 Points North Apartments 38-44 Queen
St Kings Beach QLD 4551 or Scan and email to [email protected]
Prelimenary Questions.
What has prompted you to enrol your daughter in an online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
What results are you wanting for her from the online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
What time is able to devoted by your daughter for the online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
Is your daughter in aggreance with doing the online program?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
What is your main self esteem concern for your daughter?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….
Please use this space to to add any additional information you would like Janis (Coach) to know.
