Form Embed: WoW 2019 PIF

Name*

First Last

Preferred name

First Last

Date of birth*

Day Month Year

Age*

Gender*

Address*

Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (incl country/region code)*

Email*

In case of emergency*

Name Phone number

Personal reflection*

Are you happy with your living arrangements?

very
50/50
no

Are you satisfied with your personal relationships?

very
50/50
no

Untitled*

Are you satisfied with your work?

very
50/50
no

Medical information*

Click which of these apply:

In the past I was under treatment for the following conditions. These conditions no longer require medical treatment.

Heart condition
Hypoglycemia
Asthma
Epilepsy
Diabetes
Hypertension
not applicable

Medical information*

NOW I am under medical treatment for:

Heart condition
Hypoglycemia
Asthma
Epilepsy
Diabetes
Hypertension
Pregnancy
Not applicable

If you have any other condition we need to be aware of, please explain below*

Please note: you are responsible for your own well being during the course, and we want you to follow the instructions of your health practitioner regarding medicine, diet and any special movement or seating requirements. To support you in this, please provide the following information, and remember to bring with you whatever medicine or food your health practitioner requires you to take.*

Yes; I need to have medicine, food, or special movement during the training sessions. I will check with the support staff on the training team BEFORE the training begins and receive instruction
Not applicable
Not sure; I will discuss my situation with the support staff BEFORE the course begins

Currently, I am required by my health practitioner to follow this treatment plan:

For treatment of:*

Medicine on treatment plan:*

Schedule (indicate exact times for taking medication):*

Currently I am required by my health practitioner to follow this diet:*

Dietary schedule (indicate exact times):*

Contact details of my health practitioner*

Name Phone number Email

I need special seating as a result of:*

vision loss
hearing loss

If special seating as a result of other causes, please specify:*

I require and will use the following to support myself:*

wheelchair
armchair
chair to elevate leg

Psychotherapeutic history

The More To Life Foundation and its courses are educational and not therapeutic in design or purpose. The course may involve long hours and considerable input. If you have ever been under treatment for a psychiatric or psychological disorder it is strongly recommended that you consider these facts and discuss any concerns you may have with a professional therapist prior to participating. The responsibility for such consultation is yours and is not assumed by the More To Life Foundation.

Are you currently in therapy?*

Have you been in therapy during the last year?*

Have you discussed your participation in More To Life with a professional therapist?*

Is your therapist supportive of you taking a More To Life course?*

Is your therapist available to support you during a More To Life course?*

Have you ever been hospitalized for treatment of psychiatric or psychological symptoms? If yes, when and for what?*

Confidentiality:*

I will keep confidential the personal information that is shared by the participants, team and trainers of my training. I understand that I am free to share my experience in the course, as long as the confidentiality of others are maintained.

Consent:*

I agree to all of the above and keeping confidentiality of this course and information shared by participants, team and trainers

Signed:*

Name (print) Date

Form Embed: WoW 2019 PIF

Way of a Warrior

Personal Information Form