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Are you Epileptic?

Are you currently on any prescribed medication by the GP with regards to Mental health?

If YES, please give details:

I understand that any personal data and/or sensitive personal data contained herein is processed in accordance with the data protection act 1998. Completion of this form constitutes my explicit consent for such processing. I have understood the Contra-Indications to participating at this course and know of no reason why I should not participate in this workshop

Please select the workshop/s you wish to apply for from the list below and send payment to:
Virtual Healthclub Ltd. 373 Daws Heath Rd, Benfleet, Essex. SS7 2UA

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