HOL Registration Form - Roland Bérard

Name*

First Name Last Name

Date of workshop*

Address*

Address Apt. City Province Postal Code Country

Telephone*

Email*

Gender*

Occupation*

Medication you are currently taking or have taken in the past 2 years as well as condition for which it was prescribed.*

Your physical and medical state*

Have you ever been hospitalized or treated for psychological difficulties? Has psychological treatment ever been recommended to you? If yes, what was the reason and please indicate the date and year.*

Age

Signature

Date

Woudl you like to receive more information on The Barbara Brennan School of Healing*

YES
NO

Woudl you like to receive more information on future workshops*

YES
NO

Where did you hear about this workshop?*

Registration*

Before early registration date -$275
After early registration date - $300

Payment*

Paypal
Interac
Check

Would you like to be on my mailing list?*

YES
NO

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