Open Heart: Level 3 & 4

Open Heart Level 3 & 4

Sally Mydlowec • May 9-10, 2026 • Online • 8am-4pm PST (11am-7pm EST)
Participant's Full Name (to be printed on the certificate)*
Email & Reconfirm Email*

Confirmation EmailEach participant should have his/her own unique email address. Ensure spelling is correct as important communication will be sent to the email provided above. From our experience, Zoom links are easily received by Gmail accounts.
Cell Phone*

Country CodeWhatsApp Number
Full Name of Emergency Contact*
Relationship to You (Parent, Spouse/Partner, Sibling,Friend, Other)*
Phone Number of Emergency Contact*

Country CodeWhatsApp Number
Alternative Phone Number of Emergency Contact (if available)

Country CodePhone Number
Email Address of Emergency Contact (if available)
Preferred Language (if not English) of Emergency Contact
Yes, I give my consentNo, I do not consent. I’m aware that by not consenting, I may miss out on important communication related to the workshop
Where you will be participating from?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I am Indonesia CitizenI am a KITAS/KITAP holderI am non KITAS/KITAP (tourist)
Bank Transfer to Local bank Account in local currencyPayPal (except for Australia, Indonesia, Malaysia and Singapore)
YesNo
All minor participants/below 18 years old must submit a Consent & Authorization for Minor signed form. Please download it from: http://bit.ly/NWLMF and upload it here or send to XXXX (email of Coordinator)
Parents/Legal Guardian of Minor Participant's Full Name*

PRIVACY AND TERMS OF SERVICE

Please scroll to the end of the text to tick the box
Please find below: I. Natural Way of Living Participant Code of Conduct II. Statement of Waiver and Release of Liability III. Undertaking of Confidentiality and Non-Disclosure (“Undertaking”) IV. Cancellation & Refund Policies V. Privacy Policy Please make sure that you read and understand the statements and kindly tick the box
Full Name of Participant (or Parent/ Legal Guardian of Minor)*
Date*

DayMonthYear
Date
I agree
I agreeI do not agree
I confirm that all the information given in this form is true and accurate
After clicking submit, you should receive an auto-reply from Jotform within several minutes to the email address you registered, this indicates a successful submission.
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Open Heart Level 3 & 4

WORKSHOP REGISTRATION

PRIVACY AND TERMS OF SERVICE