The Olive Harvest - An Enquiry into Connection, Conflict & Community Registration
Private and Confidential
* Required
Email address
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Your email
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)
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Your answer
Where Did You Hear About Us?
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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
adrian@evolvewellnesscentre.com
upon booking transport.
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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:
Please provide any additional appropriate information concerning your health:
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Your answer
In order to participate in our 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 ourselves.
*
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: Revolut bank Account name: Growing Movements Ltd Sort code: 040075 Account: 27477223
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