Breath to Health Workshop Registration Form (Blaenau Gwent Cohort 5)
Please fill out the form carefully for registration to attend our Breath to Health 3-day workshop (Wednesday, 17th June, Thursday, 18th June and Friday, 19th June 2026, 9.00am to 12.00pm each day). All information you provide will be handled in strictest confidence and in line with GDPR guidelines. The cost to participate is £100 (heavily subsidised from £275 thanks to Moondance Foundation funding and support from the charity International Association of Human Values). Breath to Health repeaters can simply offer a cash or bank transfer donation (an amount of their choosing).
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Address
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Emergency Contact Name
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Past Medical History:
Any Current Health Concerns
Current Medication
Registered GP Practice:
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How did you hear about us?
Word of Mouth
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Have you already attended the Mind & Body Wellness weekly sessions?
Yes
No
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Terms & Conditions
I confirm that I am participating voluntarily in the Breath to Health Workshop
Agree
Disagree
By attending the workshop, I understand that when undertaking any breathing or yoga exercises, as is the case with any physical activity, the risk of injury is always present and cannot be eliminated. I voluntarily and knowingly recognise, accept and assume this risk.
Agree
Disagree
I have fully disclosed to the Instructor any conditions that I have or may have prior to participating in these Breath to Health sessions. Whilst it is acknowledged that personal injury and/or death resulting from negligence cannot be legally waived, I release and waive any other claims for negligence that I may now or hereafter have against Thriving Communities or the Breath to Health Project Team.
Agree
Disagree
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Photography & Data Permissions
Thriving Communities and the Breath to Health Project Team may take photographs of me for any promotional materials including any of the following: social media, websites, flyers/posters. I understand I will not be identified by name.
Agree
Disagree
I agree to be added to an email list to be kept informed of future Thriving Communities and Mind and Body Wellness programme events (including the Breath to Health workshop series). I understand that my data will never be shared with a third party, and I can unsubscribe at any time.
Agree
Disagree
The data provided above will be stored and processed in line with GDPR guidelines in order that: my Instructor has knowledge of any injuries when teaching me; and I may be contacted in emergencies. I understand that I can withdraw my consent for my data to be held and/or processed at any time and that to do so I should contact Dr Manmeet Kaur at hello@thrivingcommunitiescic.org.
Agree
Disagree
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Checkout
How do you wish to pay? NB: The workshop costs £100 and is heavily subsidised thanks to Moondance Foundation funding and support from the charity IAHV - original workshop cost £275. If you are repeating the workshop, you can either select "Cash on the day" or "By bank transfer" and nominate your donation.
Cash on the day - proceed to click the Submit button
By bank transfer to Thriving Communities CIC, Account No: 76487539, Sort Code 51-61-02 (as ref use BTH-Jun25). Please select and click Submit button.
Card payment - select the number of places below and submit your card details. Proceed then to click the submit button. You will get the payment confirmation in the Jotform registration email.
Please select the number of places you wish to pay for:
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Breath to Health Workshop (Jun-26)
Fee includes a royalty fee to International Association of Human Values
£
100.00
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