Spring Programme: Norwegian Island Registration
Private and Confidential
Name *
Your answer
Email *
Your answer
Mobile Phone Number: *
Your answer
Name of Next of Kin and Telephone Number: *
Your answer
Your Organization (if any) *
Your answer
Where Did You Hear About Us? *
Your answer
How are you planning to arrive and depart to the programme? Please provide train, bus or plane details, or if not known, please email pierre.lancon@hotmail.fr upon booking transport. *
Your answer
Dietary restrictions *
Do you suffer from any of the following conditions? *
Required
Do you suffer from epilepsy? *
Do you suffer from any other condition requiring that we should be aware of including previous injuries, medical treatment and medication? *
Are you allergic or sensitive to any medication (e.g. Penicillin), insect bites or food? *
Are you taking any form of medication on a regular basis? (If so please ensure that you have adequate supplies of medication for your entire visit) *
To the best of your knowledge, have you been in contact with any contagious or infectious diseases, or suffered any recent condition that may become infectious or contagious? *
Please provide any additional appropriate information concerning your health: *
Your answer
In order to participate in a Way of Nature Programme it's essential that you have read through and agreed with our Terms and Conditions that you can view here: http://bit.ly/2g9r7Zu. Please take some time to read through it.
By clicking 'Yes' below you confirm that you have read through and understood the Terms and Conditions agreement between yourself and Way of Nature UK Ltd. *
Required
To confirm your place we ask for payment of the full amount. Please use your last name as your reference when paying into the bank account below and drop us a quick note when you have made the transfer: New World Rites Limited Bank name: Triodos Bank Sort code: 16-58-10 A/C number: 20657544
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms