Embodied Birth Experience Application Form If you have difficulty with the form, don't hesitate to ask us for help A * means that the question is compulsory, you won't be able to send the form without it. Your Details *Your Full Name *Your Address (please include your country) *Date of Birth (dd/mm/yyyy) Please upload a photo of yourself so your tutor will recognise you. Click the browse button to find your photo on your own computer, then simply select the file. It will be uploaded automatically when you send the form. Maximum file size is 1MB and acceptable file types are *.gif, *.png, *,jpg, *.jpeg. Contact us if you have difficulties! *Your email address Home Telephone (include country code if applicable) Mobile Phone (include country code if applicable) Course updates How and where did you hear about the course? You don't need to complete below unless this is where you heard about the course, and brief details are fine. Leaflets (where?) Magazine or newspaper ad (details?) Website (which one?) Other (please specify) *Would you like to join our Goddess Temple Mailing List? You will receive updates and information about courses and occasional Goddess Temple and Goddess House news. You can, of course, choose to unsubscribe at any time and, of course, you won't be added twice if you're already subscribed. yesno Information about Fees This is for information only - you can pay your fees from the Payment Page. Full Fee: Sliding scale fees paid in full at the beginning of the course: A non-refundable deposit of £200 secures your place. Scale One: Household income below £18,000 per annum: £777 Scale Two: Household income between £18,000 and £27,999: £1,333 Scale Three: Household Income above £28,000: £1,555 We hold to a policy of honesty. Payment by instalments attract a one-off £50 administration fee. Including the £50 admin fee, the payments will be (depending on your household income): Scale One: Income below £18,000: Deposit of £200 plus three monthly payments of £209.00 beginning when you receive your login to the course. Scale Two: Income between £18,000 and £27,999 per annum: : Deposit of £200 plus three monthly payments of £394.33 beginning when you receive your login to the course. Scale Three: Income above £28,000 per annum: Deposit of £200 plus three monthly payments of £468.33 beginning when you receive your login to the course. Signed Terms & Conditions are an integral part of the course application process. They need to be received by us before you receive your login to the course. Please make payments to: Glastonbury Goddess Temple. You can find the fee payment page here. Payment Options *Please select from the list below your payment preference: —Please choose an option—Pay in full in advancePay monthly by standing orderPay by monthly PayPal Subscription More about you: your experience and expectations Please fill out the following questions as fully as possible so that your tutor can get a sense of who you are. The Glastonbury Goddess Temple will hold all information given in total confidence. Each of the text areas below will expand to allow 512 characters (with a counter below to let you know where you're up to). If you need more room, please send us a separate email with further details. It will help if we can easily cross-reference an email with your form, so please include in the email your full name, address and the course you're applying for. Are you pregnant or a birth keeper? If pregnant, how many weeks are you? 0 Is there anything specific you are struggling with or would like support with? 0 If you have given birth before, how were your previous births? If you have birth trauma and prefer not to write too much we can have a conversation about it, just let me know. 0 What is your ideal dream birth? 0 Is there anything else you would like to share? 0 About your health Because the nature of these trainings is transformative and energetic it is important for the teacher to know of certain mental & physical conditions. Answering these questions enables us to ensure your safe participation within the group and to recognise those times when it may be wiser to observe rather than to participate. It is a requirement for you to answer the following questions. All information is held in total confidence. Do you suffer from any of the following conditions? (If necessary you can select multiple conditions by holding down the "Control" key and selecting as required). EpilepsyDiabetesAsthmaHigh or low blood pressureHeart condition *Do you have, or have you had, any medical problems of an acute or chronic nature? yesno *Have you ever had any mental health problems diagnosed or treated? yesno *Do you have any physical needs that it would be useful for your tutor to know about? yesno *Are you taking any drugs, prescribed or otherwise? YesNo If you have included any of the conditions above, please give details. The text area below will expand to allow 512 characters (with a counter below to let you know where you're up to): 0 Terms & Conditions We do need you to sign Terms and Conditions before you can be accepted on any course. Please download and print the Terms and Conditions now, then sign both copies and return one to us, with a note of your name and address. If you don't have access to a printer, click here to request us to send you a paper copy of the Terms and Conditions. Terms and Conditions can be returned to us by post, or may be scanned and returned by email but please note that we do need a legible copy that includes each page - we don't normally accept photos taken by a mobile phone. Terms and Conditions must be signed and returned to us within four weeks of acceptance, as well as your non-refundable deposit. Acceptance of Terms & Conditions The form won't send without your acceptance *I have downloaded the Terms and Conditions for this course, or requested a copy by post, and will sign and return them by post. I have read and agree to the Privacy Policy. Are you human? Help protect us all from automated spam by completing the simple "captcha" below. 4+8=? Δ
