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Sumiran - Life Without Medicine - Enrolment Form

Welcome to "Life Without Medicine" from Sumiran 🌿🌻

We’re glad you’re here and excited to explore this journey with you. Sumiran is more than just a place—it’s a living, breathing community where nature and people thrive together. This program is designed to help you become healthier and have a life free from medicines through lifestyle and dietary changes.

Please fill out this form carefully. Your responses will help us tailor the program to your needs. We look forward to learning more about you! 💛

Personal Information

1. Start Date of LWM Course

2. What is your name?

3. What is your Gender?

3. What is your Gender?
A
B
C

4. What is your Age?

5. Please fill in your Date of Birth

6. What is your Marital Status?

7. What is your email address?

8. What is your mobile number?

9. What is your Profession/ Vocation?

10. What is your address?

Lifestyle & Expectations

11. What motivates you to join the Life Without Medicine Program?

12. Have you tried any natural healing practices before? If yes, which ones?

13. If you have any dietary restrictions or food allergies, then specify?

14. Are you comfortable with a vegetarian, organic diet during the program?

15. Do you have any physical limitations that we should be aware of?

16. What do you hope to achieve from this program?

17. Do you have any health issues? If yes, please mention them:

18. Are you currently taking any medications? If yes, please list them:

19. How did you come to know about the Life Without Medicine (LWM) program?

19. How did you come to know about the Life Without Medicine (LWM) program?

Package Selection & Payment Details

Although you are unable to join the upcoming April 10th batch, you may still select your preferred accommodation for future batches. It will help us give you priority booking.

20. Which accommodation option are you enrolling for?

🏡 Cottage (With Attached Toilet) (Includes 3 Nights 4 Days, shared accommodation, organic meals, course presentation, learning material and program activities)
20. Which accommodation option are you enrolling for?
A
B
C

🛏️ Dormitory (Includes 3 Nights 4 Days, shared accommodation, organic meals, course presentation, learning material and program activities)

D
E

21. Have you completed the payment? (Yes / No)

21. Have you completed the payment? (Yes / No)
A
B
If No, please complete the payment and provide the transaction details below before submitting the form. You may make the payment to Sumiran Ecological Foundation's HDFC Bank Account No. 50200035764504 having IFSC Code: HDFC0003662.

22. Transaction Receipt Number / Payment Reference ID & Payment Date

23. Upload Payment Screenshot (if available)

Agreement & Declaration

24. I understand that this program is based on achieving deep conceptual clarity, lifestyle and diet modifications. I take full responsibility for my health decisions and agree to follow the program’s guidelines.

24. I understand that this program is based on achieving deep conceptual clarity, lifestyle and diet modifications. I take full responsibility for my health decisions and agree to follow the program’s guidelines.

25. Would you like to receive updates on Sumiran’s future programs & events? (Yes / No)

25. Would you like to receive updates on Sumiran’s future programs & events? (Yes / No)

Submission & Contact

Our team will review your response and get in touch with you shortly. If you have any questions, please contact us at 8770673594 or visit us at https://sumiran.org.

📍 : Sumiran Ecological Foundation, Barkheda Bazyat, near Sagoni Village, Bilkisganj, Dist. Sehore, Madhya Pradesh
📞 : 8770673594
🌐 : https://sumiran.org