PWHT Registration Form

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Please complete the form to the best of your ability. Leading up to the SKY Resilience Training (formerly Power Breath), one of the instructors will reach out to you for a brief pre-workshop check-in to answer your questions and review your registration form with you. If you have any questions about the registration process, feel free to reach out to Leslye.moore@pwht.org THIS FORM AND YOUR RESPONSES ARE KEPT CONFIDENTIAL

Email *

SKY Resilience Training June 14 - 18, 2023 Pacific Time. Wed - Fri 6:30 - 9:00 pm, Sat & Sun 10:00 am - 1:00 pm Pacific Time. Teachers: Leslye Moore / Lee Farrow

First Name *

Last Name *

Address

City *

State *

Zip

Home Phone

Cell Phone *

Emergency Contact & Phone *

Date of Birth (Must be at least 18 years old)

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Gender *

Participant Designation *

Branch of Military Service (only Veteran need respond)

Military Status

Deployment information (optional)

How did you hear about the course?

Briefly describe your mental and physical health *

Please indicate if you have any of these conditions: *

Asthma

Diabetes

Emphysema

seizures/Epilepsy

Heart Disease

Stroke

Bi-polar

High Blood Pressure

Depression

Anxiety / Panic disorder

Traumatic Brain Injury

Pregnancy

Post-Traumatic Stress

Schizophrenia / Schizoaffective disorder

NONE

Yang lain:

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If you are you presently under the care of a physician, or psychiatrist, or have been recently hospitalized, please describe :

Please list any health problems or recent health concerns (mark N/A if none): *

Please describe in detail medications you are taking:

Please list dates, course name and experiences with any meditation techniques or other self-development courses/techniques you have done

Agreement

It is compulsory to attend all sessions of the course. Taking notes and use of tape recorders is prohibited. Agreement: I understand that any benefits derived from this course depend upon the extent of my participation. I therefore accept full responsibility for the outcome and I willingly agree to follow all instructions and participate fully. I also agree that I will not disclose the content of this course to anyone. I further agree that I will not attempt to instruct others in any of the techniques used in the course until such time as I receive personal training from Project Welcome Home Troops or IAHV. By entering my name and date below I agree to the above.

Signature *

Today's Date *

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