Account Setup Membership Information You have selected the Participant membership level. For general participants Provides access to events and content The price for membership is $0.00 now. Account Information Username Password Show Password Confirm Password Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in here Registrant information First name Last name Phone Mailing Address City State/Province Postal code Country Date of birth Previous breathwork experience Please describe the extent of your breathwork experience, including what types(s) of breathwork Tell us about your interest Please write a few sentences about your interest in workshops How did you hear about us? Let us know how you found us Health cautions Breathwork sessions can involve intense experiences accompanied by strong emotional and physical release. Certain medical and psychiatric conditions may be contraindications, or they may simply require additional follow up with you in advance to provide for your comfort and safety during your session. So we can advise you properly, please answer the following questions. We will keep your answers confidential. Your information will help us support you more fully during your experience. Thank you. If you have any questions before registering, please contact us: contact@dreamshadow.com. Dreamshadow Transpersonal 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. Do you have any of the following? Please explain any Yes answers in the Additional information field at the end of the section. Cardiovascular disease, including angina or heart attack No Yes High blood pressure No Yes A personal history of psychiatric diagnosis or psychiatric hospitalization No Yes Surgery, inpatient or outpatient No Yes Past or recent significant physical injuries No Yes Recent or current infectious or communicable diseases No Yes Glaucoma No Yes Retinal detachment No Yes Seizure disorder (epilepsy) No Yes Osteoporosis No Yes Back problems No Yes Sleep problems (apnea, snoring, etc.) No Yes Additional information Please explain any Yes answers to the above or enter "None" Please answer the following questions. Please explain any "Yes" answers in the Additional information field at the end of the section. Have you been advised (by a doctor or other health care provider) to restrict your physical activity in any way? No Yes Do you have asthma? No Yes If you do, please bring your inhaler and call our attention to it at the workshop. Are you pregnant? No Yes Are you currently in therapy or in a support group? No Yes Are you currently taking any medication? No Yes If yes, please specify in the Additional information field at the end of the section. Do you have any other physical problems? No Yes Is your general health good? Yes No Is there anything else about your physical or emotional situation that you would like us to be aware of? No Yes Additional information Please explain any Yes answers to the above or enter "None" Approximate date of last routine physical exam Specify any special dietary needs. Vegetarian, gluten-free, allergies, or any other or enter "None" Emergency contact Name, phone number, and relationship to you. Please read and confirm the following statement. I hereby confirm that I have read and understood the above questions and have answered them all completely. My general health is good. I understand that if I am experiencing any cold or flu-like symptoms the week the workshop starts I will not attend. If I develop such symptoms during the workshop I will inform the facilitators as soon as possible. I understand that if I cancel my registration within ten days of the start of the workshop, I may be responsible for a cancelation fee of up to 50% of the workshop fee. I consent to being added to your Constant Contact list for workshop communications Check Out With PayPal Processing...
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