50HR Women's SelfCare Training Waiver Form

Please rest assured that all the information you've shared will be treated with the utmost confidentiality.

Name

Date of Birth (DD/MM/YYYY)

Phone Number Including Country Code (ex. +1-555-555-5555)

Country of Passport

Passport Number

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone Number Including Country Code

Emergency Contact Email Address

Describe yourself. What gives you plesure? What gives you pain? What do you feel at this point in your life your dharma is?

Dietary Requirements: Do you have a special diet? Are you allergic to any foods?

Are you currently taking medication? Which ones? Why?

Do you have any injuries, physical or mental health conditions that may need medical attention during the training?

How did you first learn about this program?

Accommodation Name and Address

Accommodation Contact Number

Question or Comment

We won't send spam. Unsubscribe at any time.