Registration Form
This form will take approximately 15-20 minutes to complete.
Name *
Name
Phone *
Phone
(We'd love to thank them!)
Date of Birth *
Date of Birth
Unisex Sizes
Early Childhood Recollections
Early recollections illustrate how we dealt with events or incidents in our early childhood and how we felt at that time. Below please describe two (2) early childhood recollections. An early recollection is the memory of a specific event or incident that occurred to you in childhood. An example would be: Age 4-5 --- One day riding my tricycle the neighbor’s dog started barking and running toward me. The dog was on a leash, but I fell off my tricycle and ran home crying. My brother laughed at me and my mother sent me to my room until I calmed down. I felt scared, embarrassed, small, misunderstood, and unlovable.
Informed Consent
I understand that this course is educational in nature and is not psychotherapy or a substitute for psychotherapy. I understand that in submitting this form, I assume the risk of any accident or injury to myself or inflicted by me during this workshop and hereby release Personal Power and Prosperity, Inc. from the liability therefore. I take responsibility for consulting with a medical doctor and/or mental health professional prior to participating in the workshop in regards to any known or potential physical or mental conditions which I have or may have. I assume the risk, by consent, of any illness during the workshop, and hereby release Personal Power and Prosperity, Inc. from any liability therefore.
Enrollment Agreements *
By enrolling, I agree to: [check all]
Please check all meal preferences / restrictions that apply: *
We want to ensure that your needs are met in the way you prefer them to be during the weekend. Tell us your Love Language! Note: This is the way you prefer to RECEIVE love, not give love. Not sure? Take this quick test: http://www.5lovelanguages.com/