Expression of interest – Term 3 Name:* Address:* City Postcode E-mail:* Phone:* - Partner attending?*YesNo If yes, please state partner name, e-mail and contact phone number: Ethnicity:* Do you have any medical conditions?YesNo If so, please give the name and contact details of an emergency contact: Family name, gender and age of child(ren) (please list all):* What parenting challenges are you facing at the moment?* Please tell us how you heard about this course:* Are you aware of any other person(s) registered for this course?* Payment options:*$120 per individual$195 per coupleIf unable to afford the above then please contact us to discuss other payment options. reCAPTCHASubmitReset