Holotropic Breathwork Registration Form
March 13-15th, 2020 • Moth and Moon Studio • Bedford, NH
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Email *
Name: *
Address: *
Phone: *
Date of Birth: *
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Emergency Contact Name, Relationship & Phone Number: *
Dietary Restrictions & Food Allergies:
We will do our absolute best to accommodate everyone's dietary restrictions for shared meals. If we anticipate any difficulties in serving you we will reach out prior to the workshop, and ask you to bring something for yourself.
Have you participated in Holotropic Breathwork before? *
What interests you in Holotropic Breathwork at this time? *
Do you have personal experience working in non-ordinary states of consciousness? *
Do you have questions or concerns about participating in this process? *
Is there any other personal information you would like to share with us? (Medical related information can be reported on the next form.) *
Would you like to be added to our mailing list to be notified about upcoming workshops? *
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