Way of Nature Journey for Women
June 4th-7th 2021
* Required
Name
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Your answer
Email
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Your answer
Mobile Phone Number:
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Your answer
Name of Next of Kin and Telephone Number:
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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?
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Your answer
Dietary restrictions
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None
Vegetarian
Vegan
Kosher
Gluten-free
Other:
Do you suffer from any of the following conditions?
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Asthma
Chest Problems
Fainting
Heart Troubles
Tuberculosis
Bronchitis
Diabetes
Migraines
Raised Blood Pressure
Angina
If you answered ‘yes’ to any of the above, please provide accurate details below:
Other:
Required
Do you suffer from epilepsy?
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Yes
No
If yes, please write below A) What specific epilepsy syndrome have you been diagnosed with and any patterns
Other:
Do you suffer from any other condition requiring that we should be aware of including previous injuries, medical treatment and medication?
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Yes
No
If yes, please provide accurate details below:
Other:
Are you allergic or sensitive to any medication (e.g. Penicillin), insect bites or food?
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Yes
No
If yes, please provide accurate details below:
Other:
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)
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Yes
No
If yes, please provide accurate details below:
Other:
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?
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Yes
No
If yes, please provide accurate details below:
Other:
Please provide any additional appropriate information concerning your health:
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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.
*
Yes
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: Bank name: Co-operative bank Account name: Way of Nature Ltd Sort code: 089299 Account: 69683358 BIC: CPBKGB22 IBAN: GB27CPBK08929969683358
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