Registration form for individual members

Please complete this form with your details if you are signing up as an individual for annual membership to Earth Heal. All info that is shared is treated with complete confidentiality.

Q1 - Q6 require an answer, but feel free to include as much or as little info as you like for Q7 - Q10.

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 the eyes showing, to: earthhealadmin[at]gmail[dot]com

Thank you for registering as an EH 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. E-mail address to which reports and feedback can be sent after each event

* 4. Please let us know which category applies :

* 5. Please indicate the payment method being used to pay the annual membership:

* 6. Date of payment:

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

* 8. Please list any health issues you need help with, surgeries you have had and medications being taken:

* 9. 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.:

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