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.

* 1. Name:

* 2. E-mail address:

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

  One Two Three Four Five
Seniors (over 65)
Children (under 18)

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

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

* 6. Date of payment:

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

* 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: