Page 1 of 1

Sumiran - Life Without Medicine - Webinar (Enrolment Form)

Welcome to the Online Webinar of "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 online webinar is designed by Sumiran’s Life Without Medicine team, 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 webinar to your needs. We look forward to learning more about you! 💛

Personal Information

1. Date of LWM Webinar

2. What is your full name?

3. What is your Gender?

Male

Female

Other

4. What is your age (years)?

5. What is your email address?

6. What is your mobile number?

7. What is your Profession/ Vocation?

8. City/ Town/ Village of Residence?

Lifestyle & Expectations

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

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

11. Have you completed the payment to Sumiran’s UPI id - 8770673594@ybl? (Yes / No)

Yes

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 UPI id - 8770673594@ybl

12. Transaction Receipt Number / Payment Reference ID & Payment Date to Sumiran’s UPI id - 8770673594@ybl

13. Upload Payment Screenshot of Payment made to Sumiran’s UPI id - 8770673594@ybl

Size limit: 10 MB

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