PACKAGES FORM DETAILS 1General Details2Child Details3Packages Details FAMILY DETAILSName First Name Last Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth MM slash DD slash YYYY Mobile No. Email Address INFORMATIONHow do you know about us?(Required)Member Referral(Required)EMERGENCY CONTACTName Relationship Mobile No. STUDENT ADDITIONAL DETAILSEDD (Estimated Delivery Date) MM slash DD slash YYYY Medical Conditions / Allergies CHILD (1) DETAILSName First Name Last Name Gender F M Date of Birth MM slash DD slash YYYY Relationship Father Mother Grandparent Other Medical Conditions / Allergies CHILD (2) DETAILSName First Name Last Name Gender F M Date of Birth MM slash DD slash YYYY Relationship Father Mother Grandparent Other PACKAGES DETAILSPlease select the service you are booking:Private Aqua, Fitness & Therapy ServicesPrivate Swimming ClassesPrivate Group Swimming ClassesPrivate Aqua, Fitness & Therapy Services(Required) Private Aqua Service Private Fitness Service Private Therapy Service Private Aqua Service(Required) Aqua Pregnancy Aqua Flow Private Fitness Service(Required) Prenatal Postnatal Women Private Therapy Service(Required) Watsu Myofascial Release Diastasis Recti Private Swimming Classes(Required) Adult Swimming Classes Baby Swimming Classes Private Group Swimming Classes(Required) Baby Swimming Classes Location(Required) Home visit Inspire Mum & Baby Centre Preferred DaySubject to AvailabilityMondayTuesdayWednesdayThursdayFridaySaturdaySundayPreferred Range of TimeSubject to Availability11AM - 12.30PM1.30PM - 3PM3.30PM - 5PM5.30PM - 7PM7PM - 8.30PMTrialFor Private Aqua, Fitness & Therapy Services 5 Sessions 10 Sessions TrialFor Private Swimming Classes 5 Sessions 10 Sessions TrialFor Private Group Swimming Classes 5 Sessions 10 Sessions Total Credit CardPlease check your Stripe API Settings. Click the "Connect with Stripe" button to use Stripe.
