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Holotropic Breathwork Registration Form
September 24-25, 2022 • Manchester, NH
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Email
*
Your email
Name:
*
Your answer
Complete Mailing Address:
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Your answer
Phone:
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Your answer
Date of Birth:
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MM
/
DD
/
YYYY
Emergency Contact Name, Relationship & Phone Number:
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Your answer
I am registering for:
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Saturday and Sunday
Saturday ONLY
Sunday ONLY
Have you participated in Holotropic Breathwork before?
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Yes
No
What interests you in Holotropic Breathwork at this time?
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Your answer
Do you have personal experience working in non-ordinary states of consciousness?
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Your answer
Do you have questions or concerns about participating in this process?
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Your answer
Is there any other personal information you would like to share with us? (Medical related information can be reported on the next form.)
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Your answer
Would you like to be added to our mailing list to be notified about upcoming workshops?
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Yes
No
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