SMOKENDERS ENROLMENT FORM

SMOKENDERS
F + 086 515 8035
C + 082 887 4768
ilana@smokenders.co.za
ENROLMENT FORM
Name:. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cell: . . . . . . . . . . . . . . . . . . . . .
Work: . . . . . . . . . . . . . . . . . . .
Home: . . . . . . . . . . . . . . . . . . . . .
Fax: . . . . . . . . . . . . . .
E-mail address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discovery Health Membership no: . . . . . . . . . . . . . . . . . . .
Membership status:
Dependant
Principal
Spouse
Division: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Call Centre:
YES
NO
PLEASE NOTE: In order to secure a place in the group of your choice, this form should be completed and returned to ilana@smokenders.co.za as
soon as possible or latest 48 hrs in advance.
Programme fee: R
;
Discovery/Vitality activation fee: R

only.
Method of Payment: (please tick)
I will deposit R
/R
and fax / scan a copy of the deposit slip.
I will transfer R
/R
electronically and fax / scan a copy of the printout.
First Na onal Bank, Northgate, Branch Code: 256-755 Account No: 622 6688 9264
Account Holder Name: The Cure Solu ons
I hereby authorize Smokenders to debit my credit card in the amount of R
/R
ONLY
Credit Card No:
(No Amex or Diners please)
CVC (3 extra no’s on back of card)
Expiry Date
Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
Print Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . .
Yes, I am registering for SMOKENDERS®
START DATES
CODE
(office use only)
LOCATION
COMPANY NAME
START TIME
YES
YES
Please read carefully and sign this section.
I unders tand that payment is payable 48 hours in ADVANC E before I s tart the programme, unles s alternative arrangements
have been agreed upon.
S ignature . . . . . . . . . . . . .
................
...............
............
Date . . . . . . . . . . . . .
Terms & Conditions Admissions Policy Smokenders programmes are for smokers who posses: 
Good communication skills 
Willingness to participate 
The desire to learn and willingness to grow 
Motivation to succeed Confidentiality Smokenders and its trainers recognises the confidentially and all private information of each participant. Smokenders and its trainers will not at any time, either directly or indirectly, voluntarily use any information for their own benefit, or disclosure, or communicate this information to a third party. The student undertakes and commits not to use or disclose any information that has been shared or disclosed during any of the Smokenders courses. Participant conduct and responsibilities Smokenders acknowledges that stopping smoking is a very important priority in a smoker’s life. Participant conduct must demonstrate this commitment and be visible in the form of full class attendance and for being open to learn. Participants are expected to reinforce the learning nature of the work by completing all written and verbal assignments. Smokenders cannot tolerate inappropriate or disruptive behaviour that compromises the learning environment. If the behaviour compromises the safety or personal rights of another individual, the participant may be subject to remedial action, up to and including expulsion from the programme. Guidelines for success For absolute success in stopping smoking, the following guidelines are imperative to follow: 1. ATTENDANCE AT ALL SESSIONS Each week’s lesson is based on the preceding week’s accomplishment. Getting second hand material is not as effective and you will be deprived of basic information designed for YOU to achieve the best possible results. 2. UNAVOIDABLE ABSENTEEISM If your absence is unavoidable, you agree to notify your trainer immediately. This is to make alternative arrangements to get the valuable information you will miss in your absence. 3. PUNCTUALITY It is agreed to be punctual for your own sake as well as the whole group. You will ensure that you have made provision in your schedule for ALL 12 meetings so that you do not have to leave before the meeting has ended. 4. FOLLOWING ASSIGMENTS It is understood that ALL assignments, whether verbal or written are IMPERATIVE to take part in and complete for the success of YOU stopping smoking. Quality and 100% money back guarantee The Smokenders smoking cessation program has been helping smokers worldwide to stop smoking since 1969. We have established a reputation and provable-­‐success rate of a minimum 92% success rate of which we are justifiably proud. It is in the interests of our clients and ourselves that we maintain this success rate. Having been smokers ourselves, and having stopped smoking with Smokenders, we know that if you attend all the meetings and complete all the assignments, you will stop smoking. Therefore, we feel confident in offering the following guarantee: •
Smokenders will refund the participants own personal contribution to the Smokenders fee to any participant who fails to stop smoking after completing two consecutive Smokenders course of 6 weeks each. •
This is conditional upon the participant attending each and every meeting, completing each and every assignment and exercise, both written and verbal. •
This is also conditional upon all Smokenders material being returned for inspections and verification. lf the delegate fails to comply with any of the above, the guarantee will become invalid. Copyright and intellectual property The participant acknowledges that Smokenders is the owner of: •
All rights to the intellectual property which includes designs, know how, copyright, goodwill and trademarks whether existing now or in the future in and to: •
All documentation, websites, Smokenders manuals and all other material that is used by Smokenders. •
The validity of these trade secrets and the copyrights protecting these materials has been established in courts of law. The participant undertakes and commits not to use or reproduce any of the material without written permission of Smokenders. Reservations and Payments All mentioned payments are inclusive of VAT. Smokenders is VAT registered at this time. The course fee is payable in full 48 hours before the commencement of the programme. Without payment and fully signed and completed registration document, the participant forfeits his/her right of a confirmed space. For part payments (by application and agreement only), Smokenders reserves the right to charge A R 150.00 administration fee. Cancellations Cancellations are only accepted in writing. All refunds will take place at the discretion of Smokenders. No immediate refunds will take place and the participant’s place will be held for enrolment for any other training within a one year period. Any cancellations received giving less than 48 hours notice will not be refunded whatsoever or transferred. If a participant does not arrive at the training, they are not eligible for any form of refund. Facilitation cancellation Smokenders reserves the right to cancel or postpone any training scheduled, although it will not be done without good reason. The participants will be informed well in time and the registration will be transferred to the next available class. I, _______________________________have read and agree to the terms and conditions mentioned above. Signature______________________________ Date__________________________________