Registration form for individual participants

Please complete this form with your details if you are signing up as an individual participant in the Equinox event on 20 March 2018. All info that is shared is treated with complete confidentiality.

Q1 - Q5 require an answer, but feel free to include as much or as little info as you like for Q6 - 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 your eyes showing, to: earthhealadmin[at]gmail[dot]com

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

* 1. Personal details:

* 2. Please give your location on 20 March 2018 (nearest town/city, state, country):

* 3. E-mail address to which reports and feedback after the event can be sent

* 4. Please indicate the payment method being used to make your exchange for this event:

* 5. Date of payment:

* 6. Your three main personal focuses for this event:

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

* 8. 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.:

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

* 10. Please tell us how you heard about this event: