Individual participant's registration form

Please complete this form with your details if you are signing up as an individual for the 21 August event. All info that is shared is 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 questions 6 - 10.

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

If you would prefer to send the form to us via e-mail rather than through this site, then instead of clicking on the "Done" button when you have completed the questions, copy and paste the form into the body of an e-mail, and send it to earthhealadmin[at]gmail[dot]com

* 1. Personal details:

* 2. Please give your location on the 21 August (nearest town/city, state, country):

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

* 4. Please indicate which payment method you used:

* 5. Date of payment:

* 6. Please list any health issues you need help 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 the treatment to focus on:

* 9. Your personal focuses for this event:

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