Wild at Heart Mindful Somatic Ecotherapy Immersion Program for Professionals
Please take your time to complete the registration form
Participant Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Region / State / Province
Postal / Zip Code
E-mail
*
example@example.com
Mobile Number
*
Format: (000) 000-0000.
Emergency Phone Number
*
Format: (000) 000-0000.
Name of Emergency Contact
*
Please check the program you are registering for. New Zealand or Australia?
New Zealand
Australia
What are you hoping to experience during the program?
*
Please share your comfort level in nature
*
Please share any previous experience therapuetically, with Ecotherapy, or NVC. Prior experience is not a pre requsite, it just helps us to better support you, knowing your experience.
There are both bunks and tent sites at the lodge please tick what accommodation your prefer.
*
I would like to camp and have my own equipment
I would like to share a bunk room
I am intending to stay off site
Other
If you chose other please share below
Please share any dietary requirements below
*
Please share any medical conditions such as allergies to bites, plants, stings, pollen etc... and or any allergies to pain or emergency medication.
Is there anything else you think would be useful to share, that would help us best support you? Emotional, medical, physical or other.
*
This is a nature based program. A significant amount of time will be outdoors. Please acknowledge that you take responsiblity for the natural risks that occur when spending time outdoors. Examples might be, slippery ground due to wet earth, or rocks, sunburn, windburn, insect bites.
I acknowledge and accept responsibility for my safety in the outdoors
For our marketing research would you please share how you heard about this program?
*
Cancellations and Refunds: There will be no refunds if your booking is cancelled later than 90 days prior to course start date unless event is cancelled by organiser. A refund less $50 admin fee will be provided outside of these cancellation dates.
Please check the box below to acknowledge you have read the cancellation policy.
YES
Your registration is not secure until payment is paid. Please check the box to acknowledge you have read this.
Yes
Submit
Should be Empty: