Ekãyano

Buddhist center in northern France

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Data form

Registration form

I want to participate in:

On date:

Name:

E-mail:

Mobile number:

Passport ID:

Date of birth:

Sex:

man

woman

Address:

ZIP code and address:

Contact details In case of emergency:

ANWB membership number:

Health insurance company:

Membership number:

Phone number:

Travel / accident insurer:

Membership number:

Phone number:

If you use medication, which one?

If you have an allergy, which one?

If you have a diet, which one?

Other things the organization needs to know?

Have you filled in the above information truthfully?

And

No

Sign (full name)

Date of signing:

Thanks for registering.

We will email you one with all further information these days.

Something went wrong for a moment. Try again or:

- mail us at info@dharma-lotus.nl

- mobile: ( 31) 0649768104

"We facilitate through peace, balance, and space so that you can facilitate your own process."

Webdesign: Ivar Mol

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