Nutrifit for Kids & Teens: Summer Intensives (Registration)
Natural Nutrition, 3rd Floor, 12 Church Street, Hamilton (opposite City Hall Car Park.)

Please complete this to reserve your spot. Online payments secure spaces. Thanks!

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* 1. Name of Kid/Teen:

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* 2. Name of Parent:

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* 3. Parent Email:

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* 4. Parent contact number:

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* 5. Teen Date of Birth:

Date of Birth

Date

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* 6. Gender:

Female

Male

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* 7. These intensives run for three consecutive evenings. All sessions are from 6pm - 7.30pm on tues/weds/thursday.

16/17/18 July 6pm - 7.30pm (TEENS - 13-17 year olds)

20/21/22 August 6pm - 7.30pm (KIDS - 8-12 year olds) ONLY 3 SPOTS LEFT

27/28/29 August 6pm - 7.30pm (TEENS - 13-17 year olds) FIVE SPOTS AVAILABLE

27/28/29 August 6pm - 7.30pm (KIDS 8-12 year olds) Runs simultaneously to Teens above, in a different group. FOUR SPOTS AVAILABLE

Please add any notes here if necessary.

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* 8. MEDICAL NOTE: Natural Ltd provides lifestyle tips and dietary advice for preventive healthcare purposes only. Our strategies are not intended as medical advice or for diabetes management (or for management of any other disease.) If your teen has a medical condition, please obtain their physicians approval prior to following our advice. Regardless of their health status, please note that neither Natural Ltd, nor our associates make any representations about the suitability for a particular individual and cannot be held responsible for any injury sustained or medical issue resulting from participation. Individuals participate entirely at their own risk. Parents are responsible for the travel of their teen to and from the venue. Teens must be signed in and out. Please indicate your acceptance of these terms by checking the box below. Thanks!

I have read the medical note and accept the terms

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* 9. The cost of the program is $380 which includes individual feedback, three evening sessions (six classes) and all printed materials. However those with a Medical Nutrition Therapy benefit from Argus or BF&M, or a Holistic Care benefit from Colonial, only need to pay the copay detailed below. Coverage depends on attendance and also on these benefits being unclaimed at the time of participation. Please note that parents are responsible for claims that can't be billed (non-attendance) or are rejected (no coverage or benefit limit reached.) Please indicate your insurance/payment option below:

Argus (your payment/copay = $120)

BF&M (your payment/copay = $100)

Colonial (your payment/copay = $180)

Other (GEHI, no coverage etc) = $380

Extra notes if necessary:

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* 10. To secure your spot on the program, please send your payment online to Natural Ltd, Clarien bank, Acc #: 4710912072 (Argus $120, BF&M $100, Colonial $180, Other $380). You also need to submit their insurance information by completing the document at the link below. You can either upload it here or email it to me at catherine@natural.bm.
Link to document (New Patient Sheet): New Patient Sheet (Teens)

If you are submitting the information now, please attach it here:

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.