Pilates Beginners Course Booking Form To register for the Pilates Beginners Course, please fill out the form below. The course will begin on Tuesday 8th January 10:00-11:00 am at the Botley Centre, 93 High St, Botley, Southampton SO30 2ES. Name* First Last Phone*Email* Address* Street Address Address Line 2 City ZIP / Postal Code Emergency Contact Name* First Last Emergency Contact Phone Number*Please tick all relevant health history Asthma Arthritis Neck/Back problems Shortness of breath Stroke Diabetes High blood pressure* Dizziness* Epilepsy Low blood pressure Overweight Chest pain* Joint problems Eye problems Heart condition* Bone/Joint damage* IF YOU ANSWER YES TO ANY OF THE ABOVE MARKED WITH AN ASTERIX* Talk to your doctor by phone or in person before you start becoming more physically active. You may be able to do any activity you want as long as you build up slowly and gradually. Or you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activity you wish to participate in and follow his/her advice. IF YOU HAVE ANSWERED NO TO ALL QUESTIONS You can be reasonably sure that you can start to become more physically active and take part in suitable exercise programme. Remember to begin slowly and build up gradually. PLEASE NOTE If your health changes so that subsequently, you answer yes to any of the above questions, inform your fitness or health professional immediately. If you feel unwell because of a temporary illness such as a cold or flu, delay becoming more active and wait until you are better.Payment InformationCost of the 6 week introductory course for beginners – £42Cost of the 6 week introductory course for beginners – £42*How would you like to pay?*PaypalDebit/Credit CardWhen you click the submit button you will be directed to PayPal to complete your payments! Debit/Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.