Learning Theatre 2017

Personal Information:

Salutation(*)
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First name(*)
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Middle name
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Last Name(*)
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I preferred to be called as
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Gender(*)
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Date of Birth(*)
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(dd/mm/yyyy)

Contact Address(*)
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Email(*)
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The email address we should contact you at.

Alternate Email
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Telephone Residential
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(e.g. +91 2242647890)

Mobile Number(*)
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Alternate Contact Number(*)
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Program Nomination Information

Program Name(*)
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Program Duration
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Accommodation type(*)
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Sponsorship(*)
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Declaration(*)
You need to accept to register


There may be some emotional stress involved in a Sumedhas program. Participants must take responsibility for self-screening if stressful situations are a concern. Sumedhas programs must not be used as a substitute for therapy or psychiatric treatment. Attendance should be discussed with a therapist if you are currently in therapy or under psychiatric treatment. You must also consult your physician, in case you have a current condition of heart ailment or any chronic illness. Should you wish to explore the nature of the program further you are invited to get in touch with any of the Role Holders of Sumedhas. You can send all queries to the Program Secretariat.
I have read the program brochure and have made a considered choice to attend. I understand that my participation in this Sumedhas program may involve stress. I have made an informed decision that my participation is appropriate for me at this time. In signing this registration form, I state that my participation is voluntary and I take full responsibility for my decision to attend.

 

Personal/ Professional and Payment Information

Name of Organization
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Designation/ Profession
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Office Telephone
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Sponsor name
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Sponsor Designation
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Email of Sponsor
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Sponsor Phone
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Payment Method(*)
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Name on Invoice(*)
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Payments Contact Person
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Contact Person Phone Number
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(e.g. +91 9864523413)

Contact Person Email
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Program Fees
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Additional Information

We would like to know you better. Please help us by responding to the following questions:

How did you hear about the website / Sumedhas?
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Please tell us whether you are a Fellow of Sumedhas(*)
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Have you attended a Sumedhas program in the past?(*)
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If yes, please share name of the last program and year in which you attended
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e.g. ESFL, 2001

Contact ability declaration(*)


I have understood what it could mean to be contacted by Sumedhas on an on-going basis. I am willing to be contacted for Sumedhas events, post the Learning Theatre Lab 2017.

Any specific registration comments
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Date
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Place(*)
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