PT Off-Peak Time Application Form Book to meet James, enjoy a chat and free consultation then decide if you want to take-up this great spring and summer offer. Just complete the form or give us a call. Name* First Last Please enter your name so we can address our responses correctlyEmail* Enter Email Confirm Email we ask you to check that it has been entered correctly so we can send your acknowledgement and reply swiftly and accurately.Phone*Please let us know how you prefer to be contacted and if by phone the best number to call you on.How do you prefer to be contacted by usEmailPhoneNo preference, don't mind whichWe want to respond by the method that suits you best, so please let us know if you have a preference.Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country address for Correspondence, if required. Personal Training wih James at Viridian Pricing Please note the Prices are as per currently displayed on My website and linked below. Please select the number of Sessions and Price that best suits your purposes. Peak Time Pricing ,br> Terms and Conditions Terms and Conditions Terms and Conditions as below, when you sign-up on this form you are accepting these terms and conditions, please ensure you read. PT Start Date* Date Format: MM slash DD slash YYYY Date of your Sign-Up for Personal Training with James Kerby at Viridian Health and Fitness.Peak Time Packages24 Sessions Peak Time18 Sessions Peak Time12 Sessions Peak Time9 Sessions Peak Time6 Sessions Peak Time1 Session Peak TimeJoint Sessions 2 PeopleJoint Single 1 SessionJoint Sessions x 12If you can train with a friend or partner, if booked as joint sessions then the Joint Price is payable in full.Total £ 0.00 Payment TermsPayment in Advance by ChequePayment in Advance by Bank TransferPayment in Advance of SessionsWould you like to receive Health and Fitness news from James and Viridian*YesNoYour privacy is important and we will respect it and not send you more than 1 news update a month maximum. Your will receive only 1 email, we will not ring you unless asked.P Sign-Up Process* YES please contact me to arrange my Free Consultation If you book your consultation before 31st January 2014 * subject to availability (places limited) then you will automatically qualify for our Festive Fitness introductory offer. Simply booking a consultation does not commit you to proceeding.Any specific message, notes or questions for James?*Please send James a message or any questions you may have and he will be in touch shortly.How did you hear about Viridian?*Personal ReferralWeb Search GoogleFacebookTwitterLinkedInWeb Search BingPinterestGoogle+OtherNot sure whereHampshire ChronicleWinchester ObserverHampshire LifePlease let us know where you heard about us or found us first.Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
