Family or group registration form

Please complete this form if you are signing up a family or group for annual membership to Earth Heal. All info that is shared is treated with complete confidentiality.

Q1 - Q6 require an answer, Q7 - Q8 are optional.

Send the 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

Thank you for registering your family or group for annual membership. We will be in touch with you soon via e-mail.

Name:

Question Title

* 1. Name:

E-mail address:

Question Title

* 2. E-mail address:

Please let us know the number of adults, seniors, children and animals in your group membership (including yourself):

Question Title

* 3. Please let us know the number of adults, seniors, children and animals in your group membership (including yourself):

  One Two Three Four Five
Adults
Seniors (over 65)
Children (under 18)
Animals
Please list the names of all the members of your group, including yourself, and their category e.g. adult:

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* 4. Please list the names of all the members of your group, including yourself, and their category e.g. adult:

Please indicate the method being used to pay for your group annual membership:

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* 5. Please indicate the method being used to pay for your group annual membership:

Date of payment:

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* 6. Date of payment:

Please tell us how you heard about the work being done by Earth Heal:

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* 7. Please tell us how you heard about the work being done by Earth Heal:

If there is any other relevant info you would like to share with us about the group or family registering for annual membership, please do so in the  box below:

Question Title

* 8. If there is any other relevant info you would like to share with us about the group or family registering for annual membership, please do so in the  box below:

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