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
*
Emergency Phone Number
*
Name of Emergency Contact
*
What are you hoping to experience during the program?
*
Please share your comfort level in nature
*
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
Please share any dietary requirements below
*
Is there anything else you think would be useful to share, that would help us best support you? Emotional, physical or other.
*
For our marketing research would you please share how you heard about this program?
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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.
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