Spanda

Register

REGISTRATION FORM

WORKSHOP: HEALING THE INNER CHILD
Date: and at

Name
Age years Date of Birth
Gender Male Female
Occupation
Address
Telephone (H) Mobile
E-mail ID

Your personal details will be kept confidential

Please be authentic, honest and specific as you answer the following:

1) Use 8 words to describe your childhood.

2) Briefly describe any challenges you face in your life right now eg. in the area of career, health, family, relationships.

3) Do you have medical problems like, diabetes, heart condition, high blood pressure, frequent headaches etc? If so, identify and state if under medication for the same.

4) Do you have emotional health issues like depression, bipolar, schizophrenia etc. If so, identify and state if under medication for the same.

5) By attending this workshop, I would like ...

I understand that this workshop involves experiential processes and I am willing to participate taking responsibility for myself.
Cancellation & Refunds: After deduction of admin fee of Rs300 refunds will be made up to 10 days prior to the workshop. Last minute cancellation deprives other people of a place. Thus for cancellations post 10 days prior to workshop, no refunds will be made unless another person makes up the stipulated number.




For online payments :

SPANDA BANK DETAILS
A/c Number: 911020068047893
A/c Name : Spanda
Account: Current
IFS Code UTIB0000009
Axis Bank
#9 Esquire Centre, A Block
M.G Road, Bangalore - 560001


For cheque payments:
Cheque to be made toward 'Spanda' and sent to:
Annie Cariapa
401/2 Palm Meadows
RG Halli
Varthur Road
Bangalore 560 066

Please let us know by email once you have transferred the amount or couriered the cheque, so that your registration and place in the workshop can be confirmed.
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