Registration and Confidential Health Questionnaire for Wild Mind Mirror Training CONSIDERATIONS, TERMS AND CONDITIONS * Please review our Considerations, Terms and Conditions before completing your registration. I have read and agree to the considerations, terms and conditions. Name * First Name Last Name Email * Contact Number * (###) ### #### Do you consent to Soulcraft ANZ sharing your contact details with other program participants? * Yes No Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Gender * Pronoun Height * Weight * Dietary Restrictions * Do you wear a Medic Alert Bracelet? * Yes No Have you ever had a heart attack? * Yes No Do you have any of the following? High blood pressure A heart murmur Heart disease Please list your blood pressure and resting pulse rate if you know it Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock? * Yes No Do you have any allergic reactions to any environmental substances, food or drugs? * Yes No Are you hypoglycaemic or diabetic? * Yes No Have you ever experienced a seizure of any kind? * Yes No Do you have haemophilia? * Yes No Do you have any disabilities of the back, knees, hips or ankles? * Yes No Have you ever had a lung disease? (asthma, emphysema, etc.) * Yes No If you walked on level ground for a kilometre at an average pace, would you get out of breath, have chest pain or leg pain, or develop muscle fatigue? * Yes No Are you taking any prescribed medications at this time? * Yes No When did you last have your tetanus shot? * How would you rate your present degree of physical fitness? * Do you have, or have you ever had, any mental health issues (e.g., depression, anxiety, panic attacks, PTSD, a psychotic episode)? * Yes No Are you currently taking, or have you taken in the past two years, any medication prescribed for a mental health condition? * Yes No Have you experienced any significant life changes in the past six months? * Yes No If you are currently (or within the past two years) receiving treatment from a medical practitioner or other health care professional for any significant physical or psychological reason, has that medical practitioner agreed to your involvement in this program? * Yes No N/A Is there anything else you feel we should know regarding your physical/psychological condition and/or history? Please specify: Name of doctor: * Phone number: * (###) ### #### In case of injury or illness, contact: Name * First Name Last Name Relationship: * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone: * (###) ### #### Work Phone: (###) ### #### Best time to call: Second Contact Name First Name Last Name Relationship Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Work Phone (###) ### #### Best time to call Program How did you find out about this AVI/SANZ program? * Are you a Wild Mind Training Program member? * Yes No Confirm Name * First Name Last Name Final acceptance of your registration is dependent on review of your health questionnaire answers and acceptance of our Considerations, Terms and Conditions. We may contact you to discuss. You will be notified of program confirmation. * Ticking this box confirms that all the details provided are complete and accurate. Date * MM DD YYYY Thank you!
