Elements - Online Booking Form


		Online Booking Form

Please complete the details below, course names and pricing are on the Activity Courses page, ensure that you read the safety terms ticked the box to acknowledge this. Please do not hesitate to contact us for any additional information. *Indicates required information.

IMPORTANT : Bookings are not confirmed until you have received confirmation from Elements.

Download the Elements Booking Form (PDF, 95Kb)

Your Personal Details
First Name *		Last Name *
Address		Home Phone *
		Work Phone
Suburb		Mobile
City		Email *
Date of Birth		Male Female
How did you hear about Elements?
Emergency Contact		Relationship
Contact Phone		Contact Mobile

Please enter the details of the course or activity you wish to do in the box below.

Your Medical, Fitness & Dietary Requirements
For your safety and enjoyment, all medical conditions must be disclosed. Failure to do so might put you at a higher level of risk.
Can you swim 50 metres?	Yes No
Can you tread water for 3 mins	Yes No
Existing medical conditions
Dietary Requirements
Any sports injuries?
Do you need prescription glasses?	Yes No

I acknowledge that I have read and understood the Elements Safety Terms.

Signature _____________________________________________________________________________