Trial Request Form

Student's Name*  
Last Name
First Name
   
Birth Date*
   
Gender*
   
Address*  
Street #/Apartment#
City
Province
Postal code
Country
   
Phone Number  
Home* (format: xxx-xxx-xxxx)
Alternate*
   
Emergency Contact  
Last Name
First Name
Phone Number
E-mail*
   
Program*
Program interests*
If other program please specify
Educational Background*  
Name of School
Trial Day
Trial Date* Select the date so we can arrange the schedule for the trial class. Thinnox counsellor will contact you regarding the confirmation.
Time option*
How did you hear about Thinnox?
(YOU MUST BE 18 YRS OR OLDER, OR A PARENT/GUARDIAN TO SUBMIT THIS FORM.)
     

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