Women's Wild Hearth
Booking form
Email address *
Name *
Your answer
Surname *
Your answer
Age range *
Address *
Your answer
Your answer
Mobile *
Your answer
Emergency contact details while you are on the course
Name & Surname *
Your answer
Telephone & address *
Your answer
Please give details of any medical conditions or allergies that you think we should know about. *
Your answer
Please give details of any particular dietary requirements here. *
Your answer
Please give details of previous relevant experience / knowledge / skills. *
Your answer
How did you hear about the course? *
Your answer
We would like to keep travel impact to a minimum and want to help you to lift share where possible. We will contact you before the course so that you can arrange lift share / requests amongst your selves
Can you offer a lift?
If yes from where and for how many people
Your answer
Do you need a lift?
Do you give permission for photographs to be taken? *
Disclaimer: I take responsibility for the state of my health and am fit to participate in yoga and the sweat lodge. *
Some personal questions
To fully participate and benefit from this course you are invited to bring yourself fully, both to support others and to be open to what may emerge for yourself. To help us in building the container of safety for the course, please answer the following questions as openly as you feel able.

Your answers will be held in complete confidentiality and will only be shared with the workshop facilitators.

Your expectations for the course. What are your reasons for joining the course and what do you hope to get out of it? *
Your answer
What’s moving or unfolding in your life right now? *
Your answer
Are there areas in your life that you feel particularly vulnerable right now that we should be aware of?
Your answer
Is there anything else you would like us to be aware of?
Your answer
Full fee £410, Medium £350, Concessions £285 depending on income. There are limited concession places and we ask for an energy exchange in the form of helping for a couple of hours on pack-up day or another way to be discussed, if needed.
You are eligible for the concessionary rate on our courses and events if you are a full-time student or receive one or more of the means-tested benefits below:

Job Seekers Allowance (JSA)
Employment & Support Allowance (ESA): Work Related Activity Group (WRAG)
Universal Credit
Housing Benefit
Council Tax Benefit
Child Tax Credit
Working Tax Credit (income does not exceed £16,190)
Income Support
Pension Credit Guarantee

Please provide details on the booking form.
Please get in touch if you feel special conditions apply or you would need to spread your remaining payments after the deposit is paid to secure your place. This can be done by setting up a standing order spreading the remaining cost over the remaining months.

Are you applying for a concessionary place? There are limited places, so please check if still available *
My total payment amount is *
Your answer
My friend for 2 friend discount is (name):
Your answer
Reason for applying for concession rate
Your answer
Please transfer your deposit & final payment to
Klaudia van Gool
sort code 08-92-86
account number 15116743
I have paid my deposit of one third of fee, amount: *
Your answer
Before sending your booking form please read the following terms and conditions.

You are fully responsible for your own health throughout this camp and therefore it is your responsibility to ensure that you are medically fit to attend.

• To secure a booking we ask for a deposit equal to a third of the overall booking fee.
The balance should be paid in full, four weeks prior to the course date.

• Once we have received your completed booking form and deposit, written confirmation of your booking will be sent to you.

• The completed booking form is your agreement with us. In sending you are confirming that you understand and agree to our terms.

• Cancellations by the participant more than 6 weeks before an event – Your booking fee will be returned minus an admin charge of £30.

• Cancellations by you less than 6 weeks before an event – Your booking fee is non-returnable.

• Cancellation by you less than 2 weeks before the event - Your full fee is non-returnable.

• In the unlikely event that we have to cancel a booking, all deposits and fees are returnable. Booking priority will be given to rescheduling the event.

A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms