• Complete the form below with your details (simply fill in your info after each item), and send back to us via e-mail.
• Send us a head and shoulders photograph of yourself, to enable us to connect to you personally at the start of the treatment. Pics should be in JPEG format, in a size UNDER 100 KB to minimise downloading time. 

Participant's details:

I would like to accept your invitation to participate as a guest in the March 21 distant healing event!

Items 1 - 6 are important for admin purposes and should be completed by all participants.

Items 7 - 12 are not crucial for admin purposes, but give us information which may be relevant to the treatment.  Include the info you would like to send to us, and which you feel may be relevant for you at this time.

1. Full Name:  
2. Gender (Male/Female):  
3. Date of birth (If unknown, please give approximate age):  
   E-mail address for receiving the reports sent out after the event:
   Place of residence (please give nearest city, state and country):
   Participant's location on March 21 (if different to place of residence):  
   A short summary of health problems (if applicable):   
   Medication being taken (if applicable):
   Surgical history (if applicable):  
   A short summary of areas of life in which a blockage is being experienced, or where a shift of energy is needed (if applicable):  
   Any problems/challenges you would like the treatment to focus on (a short summary):
   My personal focus for this event: (complete this if you want to...health, relationships or any area of your life that you would like this the treatment to focus on; can be more than one focus) 

Thank you for registering as a participant in the upcoming Equinox event on 21 March. 

Please e-mail this form to us as soon as possible, and by no later than 20 March, 2008.

Email: earthhealadmin@gmail.com • Earth Heal blog: http://earthheal.blogspot.com/