Please answer the following questions and return them by email to Mary and Jennie at the above email addresses. In order to simplify the process, please copy and paste this application, including the health questions, into the body of the email or a document that you will attach to the email. Please put your “first/last name and BES Application” in the subject line of the email. When we receive your application we will contact you with next steps. Thank you!
- Please tell us why you are longing for the Body~Earth ~Soul Journey. What draws you in about this adventure? Is there anything that feels edgy or challenging to you?
- Tell us about your readiness, your willingness, and ripeness. Why is this the right time for you to embark upon the Body~ Earth~ Soul Journey?
- Please share with us something about your past experience of gathering with women intentionally?
- Please list and describe briefly the personal development, soul-oriented work, nature-based work, or body-based work you have previously experienced?
- Please describe andy medical conditions or injuries that will impact your participation during the nature-based portion of the program. Will you need any physical accomodations?
- On our 3 day overnight session, we will be camping together at a location we will drive to (no backpacking necessary). You will be invited to do some small wanders onto the land, but can choose your distance. You’ll need to acquire on your own the necessary camping gear (borrow, rent, or purchase). Upon acceptance of your application, we’ll send you a preparation package that includes a list of camping gear, or you can contact Mary or Jennie and ask us to send you that camping list now). Here, then, is question #6: Are you comfortable with a small wander and can be prepared with a basic camping set-up?
- Please look carefully over all of the dates for our scheduled sessions. Are you able and willing to commit to attending all the sessions? Are there any dates where a conflict arises?
***Because BODY~EARTH~SOUL will take place in retreat settings and on land involving an overnight car camping session, the HEALTH QUESTIONS form is part of the application. Please fill out and include in your application. Thank you!
Confidential Health Questionnaire
Date of Birth: ____________
Gender: ________ Height: __________ Weight: ______ Age: _______
Please respond with at least a simple ‘yes’ or ‘no’ to every question here and attach additional pages if necessary.
Do you wear a Medic Alert Bracelet? If yes, for what condition?
Have you ever had a heart attack? If so, when? ___ please attach an explanation.
Do you have 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: If yes, please explain:
Do you have any allergic reactions to any environmental substances, food or drugs? If yes, please explain:
Do you have dietary restrictions or preferences that you would like us to consider when planning meals and snacks that will be offered at our gatherings? Please describe.
Are you hypoglycemic or diabetic? Specify:
Have you ever experienced a seizure of any kind? If yes, please attach an explanation.
Do you have hemophilia?
Do you have any disabilities of the back, knees, hips or ankles? If yes, please explain.
Have you ever had a lung disease? (asthma, emphysema, etc.) If yes, please explain.
If you walked on the level for a mile at an average pace, would you get out of breath, have chest pain or leg pain, or develop muscle fatigue? If yes, please explain.
If you are under the care of a physician, does he/she approve of you engaging in this activity?
When did you last have your tetanus shot?
How would you rate your present degree of physical fitness?
Are you currently (or within the past two years) receiving treatment from a physician or other health care professional for any physical or psychological reason? Please explain.
Are you taking any prescribed medications at this time? If yes, please specify the medication & the reason for which it was prescribed
Is there anything else you feel we should know regarding the condition and/or history or your body, heart, mind, psyche, life…that may have any bearing on your participation in this program, and/or that we should be aware of so that we can better support you?