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)Enter the Price of your Workshop(Required) Which Workshop are you registering for?(Required) April 27th AM Half Day 10am-1pm $60 April 27th Full Day 10am-4.30pm $120 April 27th PM Half Day 1.30pm-4.30pm $60 June 22nd AM Half Day 10am-1pm $60 June 22nd Full Day 10am-4.30pm $120 June 22nd PM Half Day 1.30pm-4.30pm $60 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 How did you find out about us? If it was through the internet please be as specific as possible.(Required)
