Registration Form | Breakthrough Breathwork Mediation

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)

Have 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)

Feb 24th Half Day - $60

Feb 24th Full Day - $120

Your Total Charge Today

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Card Details

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Street Address City State ZIP Code

How did you find out about us? If it was through the internet please be as specific as possible.(Required)