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I am applying for the selected workshop

First and last name

First Name

Last Name

Address

Phone

Email

Price

Discount / promotional code

Room: if available, I would choose

Single room
Double room
Triple room
Quadruple room

Are close to

I would share the room with

Special needs

I have special dietary needs
I need help organizing transportation
None of the above

Details of special needs

Are you currently or have you in the past suffered from any of the following diseases:

Other important health information (check if applicable)

Are you pregnant?
Have you been hospitalized for medical reasons in the past 20 years?
Have you ever been hospitalized for psychiatric reasons?
Are you currently experiencing a mental crisis?
Are you currently attending individual or group psychotherapy?
Are you currently taking any medications? (please specify which)
Is there anything else important regarding your psychophysical condition that you would like to inform us about so that we can safely support you at the workshop?
None of the above

If your answer to any of the above questions is affirmative, please be sure to write us the details regarding this here, on the last page of this document or directly in the e-mail.

Additional explanations of positive answers from the medical questionnaire:

Please provide the name of a close person to contact in case of emergency:

Phone number of close person to contact

Gender

Age

Date

I have experience with Holotropic Breathing

YES
NO

Cancellation of participation:

In case you cancel your participation in the workshop, the organizer will retain €50 of the paid amount. We will return the remainder of the payment if you cancel your participation no later than two weeks before the start of the workshop. Please DO NOT pay the registration fee until we confirm your participation in the workshop.

Signature

Holotropno Dihanje

Holotropno Dihanje

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