Family or group registration form - Human

This form should be completed by all human members included in the family or group registering for annual Earth Heal membership. All info that is shared is is treated with complete confidentiality.

Q1 - Q4 require an answer, but feel free to include as much or as little info as you like for Q5 - Q9.

Send the completed form by clicking the 'Done' button at the bottom of the page when you have finished, or if you prefer to send it via e-mail, just copy and paste the form (without clicking the "Done" button) into the body of an e-mail and send it to: earthhealadmin[at]gmail[dot]com

Please send us a head and shoulders pic, with your eyes showing, to: earthhealadmin[at]gmail[dot]com

Thank you for registering as an Earth Heal member. We will soon be in touch with you via e-mail.

* 1. Personal details:

* 2. Please give your usual residential location (nearest town/city, state, country):

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

* 4. Name of the person who arranged the group or family annual membership:

* 5. Your three main personal focuses for upcoming events:

* 6. Please list any health issues you needshelp with, surgeries you have had and medications being taken:

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

* 8. Please list any specific problems/challenges you would like upcoming treatments to focus on:

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