Registration Form Name(Required) First Last Your Age(Required)Email(Required) Phone(Required)Do you have, or have you had, any serious medical conditions such as heart problems, stroke, high blood pressure, epilepsy, glaucoma or retina detachment, a recent surgery, or psychological disorders such as schizophrenia or bipolar? If so, what?(Required)Are you currently pregnant?(Required)NoYesHave you suffered from lung disorders, or other breathing difficulties, such as asthma? If so, explain.(Required)Have you practiced any other breathwork techniques? If so, please explain.(Required)Which Workshop are you registering for?(Required) June 21st Men's Group Solstice Workshop 6.30-9.00pm July 15th Half Day - $60 July 15th Full Day - $120 Sept.16th Half Day - $60 Sept 16th Full Day - $120 Enter the Price of your Workshop(Required) Your Total Charge Today Credit Card(Required)Card Details Cardholder Name Billing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code