with Lenny and Elizabeth Gibson in Southern Vermont

Registration and Health Check Information for Breathwork Participants

Health Cautions: Because these workshops can promote strong physical and emotional release,they are not advised for persons with a history of cardiovascular disease, including angina or heart attack, high blood pressure, glaucoma, retinal detachment, osteoporosis, significant recent physical injuries or surgery. These workshops are also not suitable for persons with severe mental illness or seizure disorders or for persons using major medications. Pregnant women are advised against taking these workshops. Persons with asthma should bring their inhaler and consult with the facilitators. Persons with infectious or communicable diseases are asked to avoid these workshops. Please contact us if you have questions about these or any other medical conditions.

Holotropic Breathwork is deeply experiential and may involve intense and energetic emotional release. Workshops do not substitute for psychotherapy, but can significantly deepen and enhance psychotherapy and other healing and personal growth efforts.

Register by Mail: To register by mail, please download the PDF version of the registration and health form and follow the instructions for mailing it to us, along with your nonrefundable $25 deposit. After we receive your health form and deposit, we will send you additional information about the workshop, including more details about the schedule for the weekend, what to bring with you, and travel directions.

Register Online: To register online, please submit your information and send your $25 nonrefundable deposit via PayPal using the form below. (You don't need to have a PayPal account in order to use this feature.) After we receive your health form and deposit, we will send you additional information about the workshop, including more details about the schedule for the weekend, what to bring with you, and travel directions.

Please note: the December 1-3, 2017 workshop is full; please contact us to be placed on the waiting list as we may get cancellations.

Workshop Date (required)

Full Name (required)

Date of Birth (required)

Email Address (required)

Telephone Number (required)

Mailing Address (required)

The Breathwork experience can involve dramatic experiences accompanied by powerful emotional and physical release. Pregnancy, cardiovascular disease, severe hypertension, a family history of aneurisms, recent surgery or fractures, acute infectious disease, seizure disorder, or certain psychiatric conditions are contraindications. So we can advise you properly about this, please answer the following questions. We will keep all your answers confidential. Your information will help us create a safe setting for this experience.

Use the "Further Information" field at the end of the form to give details regarding any "yes" answers.

1. Do you have any of the following (required):
Cardiovascular disease, including angina or heart attack   
High blood pressure   
A family history of aneurysms   
A personal history of mental illness or psychiatric hospitalization   
Surgery, inpatient or outpatient   
Past or recent significant physical injuries   
Recent or current infectious or communicable diseases   
Glaucoma   
Retinal detachment   
Seizure disorder (epilepsy)   
Osteoporosis   
Back problems   
Sleep problems (apnea, snoring, etc.)   

2. Have you been advised (by a doctor or other health care provider) to restrict your physical activity in any way?   

3. Do you have asthma? (If you do, please bring your inhaler and call our attention to it at the workshop.)   

4. Are you pregnant?   

5. Are you currently in therapy or in a support group?   

6. Are you currently taking any medication?   

7. Do you have any other physical problems?   

8. Is your general health good?   

9. Is there anything else about your physical or emotional situation that you would like us to be aware of?   

10. Further Information. Please explain any "yes" answers to the the above questions (except for #8).

11. Please state any special dietary needs (vegetarian, gluten-free, allergies, or any other).

 Please check the box to confirm that you have read, understood, and completely answered the above
questions. Thank you.

After you click "Send" you will be directed to PayPal to pay your $25 nonrefundable deposit.

For additional information about any of our events, please contact us:
Elizabeth Gibson, 128 Solar Park, Pawlet, Vermont 05761
800-404-7261; contact@dreamshadow.com.

Thanks for your interest in our workshops!

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