Awakened Woman Registration

Your Full Name

What name do you like to be called?

Your Location (Town, Country)

Your Email

Your Phone

Your Social Media Channels

If you would like to connect on social media

Confirm the program you are registering for

Which is your preferred day for attending the weekly live class? (Choose from dropdown menu.)

We need your permission to send you emails. Do you agree to receive communications from Bryarly/Earth Nectar? You can unsubscribe from our email list at any time and your email address will never be shared.

Yes, I agree to receive your email communications

What do you hope to gain/experience/learn by taking this course?

What experience do you have with Tantra, meditation, yoga or other wellness practices, if any?

What are the current main stressors in your life?

Have you experienced any form of physical, sexual, or emotional abuse? (Optional to answer, but can be helpful for me to know as we embark on this journey together.)

Yes

Rather not answer

If yes to the previous question, and if willing, please briefly explain. This information is kept strictly confidential and is only asked so I can better support you. Your answer is not required.

We kindly ask you to inform us about any illnesses, diseases, recent surgeries or injuries (less than a year ago) that you have:

We will be doing physically active practices such as dance, breathwork, self-massage and dynamic meditations. Before registering for this program, consult your doctor regarding any health concerns you may have, and please be advised that you participate in the program at your own risk.

NOTHING
mental illness
recent surgery (less than 1 year ago)
cardiovascular disease
spinal injuries, fractures of the pelvic bones and lower extremities, traumatic brain injuries
other (specify below)

If you answered Other to the question above, please specify any other disorders or bodily issues that the course facilitator should be aware of.

Are you currently pregnant?

If so, congratulations! (This helps me to suggest modifications.)

Yes

Is there anything else you would like to share about yourself (e.g. preferred gender pronoun, special needs or anything else)? (Please note that this course is most suited to female-bodied participants)

Name and Phone Number of Emergency Contact

Include country code and area code

Participants will be asked to turn off their video cameras during certain intimacy practices. This is to protect your online privacy as an additional safeguard. Do you agree to turn off your video camera when asked?

Yes, I agree

No, I do not agree

Privacy and confidentiality are essential, so do you agree to a) neither video record nor audio record the class, and b) keep confidential all private information that is shared in the class?

Private information is anything that is not common knowledge.

Yes, I agree

No, I do not agree

I will be screen recording the classes so enrolled participants who miss a class can watch the screen recording to catch up. Do you consent for screen recordings to include your face and/or voice, understanding that they will only be made available to participants of this course round and only for the duration of the course? Thereafter the recordings will be unavailable for viewing.

Yes, I give my consent for screen recordings to include my face and voice, for use only as specified above.

No, I do not give my consent for screen recordings to include my face or voice.

Please read and agree to our complete Terms and Conditions and Privacy Policy (linked below) before submitting your form.

I agree to the Terms and Conditions and Privacy Policy

with Bryarly