Man to Man Application Form

Name *

Title

First name

Last name

Address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Home phone

Cell phone

Email address

Cost

Course fees includes the participants manual

Pay/Donate method

Internet Banking
Make deposit to account
03 0887 0281519 00

Cash
Cash payment

EFTPOS
EFTPOS Available onsite

Declaration

I hereby declare that I am personally responsible for my phyiscal, mental, emotional and spirtual well-being; and I will take precautions to maintain or improve these areas throughout the duration of the programme.

I understand that Careforce Lifekeys, church staff, facilitators, and group participants are in no way liable for my present or future well-being.

I understand that, should I act in any manner that would significantly prejudice the well-geitng or progress of any fellow course members, I can be required to cease attending the course.

Full Name

Date

Thank you for completing this application form expressing your interest in participating in Man to Man. The facilitator will be in touch shortly to arrange a pre course interview.