Family/group participant's registration form - Human

This form should be completed for all human participants included in the family or group participating in the 21 August event. All info that is shared is is treated with complete confidentiality.

Questions 1 - 4 require an answer, but feel free to include as much or as little info as you like for questions 5 - 9.

Thank you for registering as a participant in the event. We will soon be in touch with you via e-mail.

If you would prefer to send the form to us via e-mail rather than through this site, then instead of clicking on the "Done" button when you have completed the questions, copy and paste the form into the body of an e-mail, and send it to earthhealadmin[at]gmail[dot]com

* 1. Participant's personal details:

* 2. Participant's location on the 21 August (nearest town/city, state, country):

* 3. Would this participant like to receive the reports and feedback sent out after the event?

* 4. Name of the person who arranged the family/group participation in this event:

* 5. Please list any health issues the participant needs help with, surgeries they have had and medications being taken:

* 6. Important periods and dates in the participant's life - include traumatic or stressful times and events, accidents, injuries, deaths, births, miscarriages or abortions, divorces, marriages, loss of job, moving home etc.:

* 7. Please list any specific problems/challenges the participant would like the treatment to focus on:

* 8. Participant's personal focuses for this event:

* 9. If there is any other relevant info you would like to share with us, please do so in the box below:

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