After the Storm Nature Quest 2020

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After the Storm Nature Quest 2020 - Registration

Private and Confidential

Name *

Email *

Mobile Phone Number: *

Name of Next of Kin and Telephone Number: *

Your Organization (if any) *

Where Did You Hear About Us? *

How are you planning to arrive and depart to the programme? Please provide train, bus or plane details, or if not known, please email info@wayofnature.co.uk upon booking transport. *

Dietary restrictions *

None

Vegetarian

Vegan

Kosher

Gluten-free

Other:

Do you suffer from any of the following conditions? *

Asthma

Chest Problems

Fainting

Heart Troubles

Tuberculosis

Bronchitis

Diabetes

Migraines

Raised Blood Pressure

Angina

If you answered ‘yes’ to any of the above, please provide accurate details below:

Other:

Required

Do you suffer from epilepsy? *

Yes

If yes, please write below A) What specific epilepsy syndrome have you been diagnosed with and any patterns

Other:

Do you suffer from any other condition requiring that we should be aware of including previous injuries, medical treatment and medication? *

Yes

If yes, please provide accurate details below:

Other:

Are you allergic or sensitive to any medication (e.g. Penicillin), insect bites or food? *

Yes

If yes, please provide accurate details below:

Other:

Are you taking any form of medication on a regular basis? (If so please ensure that you have adequate supplies of medication for your entire visit) *

Yes

If yes, please provide accurate details below:

Other:

To the best of your knowledge, have you been in contact with any contagious or infectious diseases, or suffered any recent condition that may become infectious or contagious? *

Yes

If yes, please provide accurate details below:

Other:

Please provide any additional appropriate information concerning your health: *

In order to participate in a Way of Nature Programme it's essential that you have read through and agreed with our Terms and Conditions that you can view here: http://bit.ly/2g9r7Zu. Please take some time to read through it.

By clicking 'Yes' below you confirm that you have read through and understood the Terms and Conditions agreement between yourself and Way of Nature UK Ltd. *

Yes

Required

To confirm your place we ask for payment of the full amount. Please use your last name as your reference when paying into the bank account below and drop us a quick note when you have made the transfer: Don't forget to enter this reference: 02887188 Name: Way of Nature Account: 04436667 Sort Code: 23-69-72 IBAN: GB47 LOYD 3080 1214 0888 68BICLOYDGB2L Beneficiary Address: Revolut LTD, Level 39, 1 Canada Square, London

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