WM2: Registration

The Warrior Monk II: ASA

Registration Form / Confidential Health Questionnaire

Date/location of training you are registering for:

Next WM2 is at 12/29/15 on Whidbey Island

Name*

First Last

Age*

Address*

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

Primary Phone

Work Phone

Email*

Relationship Status*

Work / Profession*

Emergency Contact*

Emergency Contact Phone*

Confidential Medical and Health Information

1. Are you under a physician’s care? If so, please describe.*

2. Do you have an injury or illness that may restrict your movement?*

3. List any medications you are currently taking and why?*

4. Have you ever been treated or hospitalized for alcoholism, drug addiction, depression, emotional problems or mental illness? If so, please describe*

5. Have you worked with a therapist in the past or are you currently in therapy? Was/is it a positive experience?*

6. Is there anything else about your physical or emotional status we should be aware of?*

7. Do you have any special dietary needs? (i.e. vegetarian, no wheat, etc.)? If yes, please describe.*

8. Do you have a past history or currently experience any of the following?*

If none, please select 'None of the above'

2000+20=*

Please enter a number from 2020 to 2020.

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WM2 Registration

The Warrior Monk II: ASA

Confidential Medical and Health Information