Registration for September 17-22, 2019 Five Day Bodywork Training Retreat

Registration and Health Check Information for September 17-22, 2019 Five Day Bodywork Training Retreat

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 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.

Workshop Date (required)

—Please choose an option—September 17-22, 2019, Pawlet, VT

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 (#10) of this form to give details regarding any "yes" answers.

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

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

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

4. Are you pregnant?   YesNo

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

6. Are you currently taking any medication?   YesNo

7. Do you have any other physical problems?   YesNo

8. Is your general health good?   YesNo

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

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

11. Specify any special dietary needs for your meals here (vegetarian, gluten-free, allergies, or any other).

12. About you: please write a few sentences about yourself so we can get to know you a bit before the workshop.

13. Emergency Contact name, phone number, relationship to you.

 Please check the box to confirm that you have read, understood, and completely answered the above
questions. After you have clicked "send" you will be directed to PayPal to pay your $25 nonrefundable deposit. Please allow a few moments for the PayPal page to load.