Plantcestral reMembrance for SWANA Healing
Please fill out this registration form so that I can better coordinate our class. Thank you!
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Name: *
Email: *
Phone Number: *
Please also note if you are responsive and okay with receiving text message communication.
Gender identity (ies):
Please also share your preferred gender pronoun(s)
What city/state/country do you currently live in? Please share the exact mailing address you'd like your herbal package to be sent to. *
Where do your ancestors come from? What specific part(s) of the SWANA region do your SWANA ancestors come from? *
If you are mixed race, please feel welcome to share all of the different regions/countries your ancestors come from. This info will help me better honor you and your ancestors as I prepare for our course.
What inspires you to join this class? What do you hope to gain from participating? *
Is there any 1 particular SWANA plantcestor you would love to learn more about? Please name it, if so.
Do you have any health conditions? Please list them. Please also list any prescription medications you take. Please also note if you are pregnant or possibly pregnant. *
This info is confidential. This information will allow me to encourage greater safety throughout the course of herbs we will be using during the class.
Please select ALL the times that you are available to meet. *
Please be as flexible as possible so that we can accommodate participants in different time zones.  If none of these times work for you, please state your needs in the "other" box or the comment section below.
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How/ from whom did you learn about this class?
Do you have any other questions, comments or concerns to share with me? Please do so here.
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