Deep Rest Tuscany Retreat Registration
Private and Confidential
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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 adrian@evolvewellnesscentre.com upon booking transport. *
Dietary restrictions *
Do you suffer from any of the following conditions? *
Required
Do you suffer from epilepsy? *
Do you suffer from any other condition requiring that we should be aware of including previous injuries, medical treatment and medication? *
Are you allergic or sensitive to any medication (e.g. Penicillin), insect bites or food? *
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) *
Please provide any additional appropriate information concerning your health: *
In order to participate in our 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 ourselves. *
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: Bank name: Revolut bank Account name: Growing Movements Ltd  Sort code: 040075    Account: 27477223
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