Public Programme Registration

Order Number

First Name *

Last Name *

Email Address *

Phone number *

Where did you hear about this program? *

Location in India *

Who will attend? *

Myself, alone

Myself, with partner/spouse

Myself, with teenager(s)

Myself, with parents/elders

Myself, with friends/family

Myself, with work/colleagues

My child/children, by themselves

My partner/spouse, by themselves

My parents/elders, by themselves

My friends/family, by themselves

Other

How many of you will attend? *

Which is the most convenient time for you to attend? *

Who do you represent?

Yourself, an individual

A group of individuals

A company/firm

Which format are you most interested in? *

3 Hour Capsule

8 Hour Workshop (1 Day)

16 Hour Programme (2 Days)

Of the three parts of this program, which interests you the MOST? *

Stress & Anger Management

Nutrition & Wellness

Relationships & Communication

Of the three parts of this program, which interests you the LEAST? *

Stress & Anger Management

Nutrition & Wellness

Relationships & Communication

In health and wellness, what interests you the most? *

Nutrition related

Dental related

Mental health related

Lifestyle related

Physical fitness related

Other

Are you a health/wellness professional? *

Yes, I am

No, I am not

Are you associated with any form of health or wellness, such as a doctor, nutritionist, physiotherapist, chiropractor, psychologist, spa therapist etc.?

Do you have a health/wellness related business or product? *

Yes, I do

No, I do not

Are you associated with any form of health or wellness based business, such as a gym, healthy food, supplements, spa etc.?

Would you like to make a presentation on health and wellness at our event? If Yes, please leave details below. *

Yes, I would

No, I would not

If you answered 'Yes' to the previous question, please leave details here.