Rebooking Purchase Form 4

To make sure you are rescheduling for the correct course date, please view the Breath for Life website: courses page for dates and times.
PLEASE NOTE: When you have decided on the date please come back to this form to register. DO NOT register through the website or you will be paying full fees which will not be refunded.
Date of Original Booking*
Course Name:*
Receipt #:*
Date of New Booking*

Registrant Full Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email

The Breath for Life office will email you a revised confirmation.receipt within 24 to 48 hours. Please visit the courses page of our website for immediate course information. Please also check your spam or junk folder if the email does not appear in your inbox.
Course Rebooking ($70+GST)
Price:
By rebooking into this course you agree to the policies and procedures of your previous course booking. This reschedule represents your final opportunity to complete this course. Breath for Life will not accept any further reschedules.
- I Agree
Credit Card
Card Details
Cardholder Name
Please Note:

Provide debit or credit card information in the payment section below and click on the submit button to complete your registration and payment.
CAPTCHA
You must complete the captcha and then press submit. When you press submit you will see a turning circle. This means that your payment is being processed. Please allow time for processing and do not exit out. Thank you.