HEARTS GOING TOWARDS WELLNESS
REGISTRATION INFORMATION
Event: Hearts Going Towards Wellness Conference Director: Linda Ross
October 21-25, 2015 Direct: 907-952-2847-cell
16453 E. Clark Rd. Palmer, Alaska 99645 (Lazy Mountain) Fax: 907-395-0633
Cost: $200 Email:
PERSONAL INFORMATION(Please Print Clearly)
Legal Name:______□Female □Male
Name you would like shown your name tag: ______
Ethnicity: □Alaska Native □American Indian □White □Other: ______
Marital Status: ______Age: ______
Address: ______
City: ______State: ______Zip: ______
Daytime Phone: (____)______Evening Phone: (____)______
Email Address: ______
Church Denomination: ______
TRANSPORTATION INFORMATION
Note: Participants in the Anchorage area will be responsible for their own transportation. Other’s flying in should schedule to arrive in Anchorage prior to or day of registration October 21. Participants should plan to arrive at Lazy Mountain outside of Palmer not later than 4:30 pm October 21 to register.
Note: Once your application is received and approved, you will be notified for your particular transportation need. So for those flying in, transportation from Anchorage to Palmer will be provided.
Note: I will need ground transportation to Palmer? yes ____ no ____
LODGING INFORMATION
Note: Lodging will be provided beginning Wednesday October 21, and ending Sunday noon October 25.You will stay in lodging at the InterAct Facility on Lazy Mountain. Upon acceptance, a detailed map will be sent to you later. If you have special lodging needs, diet concerns, etc. or if your flight schedule requires an early arrival, please contact Linda 952-2847 or Alan Ross 942-4100 in advance for assistance.
Please specify name of person you would prefer to room with:______
Please return these forms by mail to the address at the bottom of the applicationASAP
- REGISTRATION FORM
- RELEASE OF LIABILITY
- EMERGENCY RELEASE INFORMATION FORM
- Please make checks or money orders payable to Alaska Freedom Journey
- A non-refundable $20.00 pre-registration fee will be charged to all participants
- This pre-registration fee will hold your reservation, and the remaining conference fee of $180.00 MUST be paid in full at registration time on October 21, 2015.
Hearts Going Towards Wellness
Linda Ross Director 203 Linwood LN. Kenai AK, 99611-8114 phone/fax (907) 395-0633
HEARTS GOING TOWARDS WELLNESS
PRE-GROUP QUESTIONNAIRE
HGTW OCT 21-25, 2015
(Please Print Clearly)
Last Name______First Name ______
Female___ Male___Age____ Marital Status______Number of Children ______
City______State____ Phone (____)______E-Mail______
Church Denomination______
(A large part of the seminar will involve being in a small group. In order to facilitate placing you in a group that will best meet your needs, we need you to respond to these questions. Your answers will be confidential and will be seen only by the appropriate Hearts Going Toward Wellness leadership.)
1. Would you like to be considered for a co-ed group?*Yes:______No:______No preference: ______
(*There is a possibility of co-ed leadership for any group.)
2. Were you wounded, harmed or abused in any of the following ways?
Domestic/Spousal?Yes__No__If yes, age:___ Relationship of offender to you: ______
Emotional? Yes__No__If yes, age:___ Relationship of offender to you: ______
Physical?Yes__No__If yes, age:___ Relationship of offender to you: ______
Sexual? Yes__No__If yes, age:___ Relationship of offender to you: ______
Spiritual?Yes__No__If yes, age:___ Relationship of offender to you: ______
Verbal? Yes__No__If yes, age:___ Relationship of offender to you: ______
Satanic Ritual Abuse? Yes__No__If yes, age:___ Relationship of offender to you: ______
4. At what age did you first talk about your wounds/abuse?______
Who did you talk to? ______What was their response? ______
5. Have you received lay or professional counseling in the past? Yes ______No ______
If yes, for what reason(s)? ______
6. Are you currently in counseling? Yes__ No___ If yes, for what reason(s)?______
** If you are currently in counseling, please have your counselor read the accompanying letter and complete the release form.
7. Have you struggled with any addiction/addictive behavior? Yes______No______
8. Are you currently struggling with any addiction/addictive behavior? Yes______No______
9. NOTE: To maximize your experience at HGTW conferences, it is HIGHLY RECOMMENDED that each applicant has a minimum of 30 days sobriety.Please explain if you answered Yes to question 8 or if you have not had a minimum of 30 days sobriety : ______
Additional comments: ______
______
HEARTS GOING TOWARDS WELLNESS
Emergency RELEASE Information
(Please Print Clearly)
Last Name ______First Name ______
If there is a medical/emotional emergency involving me, I release InterAct Ministries, Alaska Freedom Journey, Hearts Going Towards Wellness, and LEaD Alaska to contact:
Emergency Contact Information
Name______Phone Number (____)______
Relationship to you______Alternate Phone (____)______
Address______
City______State______Zip______
And, if applicable:
Name of friend/relative with you at Hearts Going Towards Wellness
Name______Relationship to you:______
Name of doctor:
Name______Phone (____)______
Medical Information
Please PRINT any allergies, medications, illnesses, special needs, or disabilities:
______
Insurance Company ______
Insurance Claim Office Address ______
Policy Number ______Group Number ______
Phone Number ______
Name of Policy Holder ______
Your Signature ______Date ______
HEARTS GOING TOWARDS WELLNESS
In consideration of my electing to and being able to participate in the small group ministryheld at the InterAct Ministries Facility on Lazy Mountain in Palmer Alaska,
I, ______ (print name of participant), for myself, myheirs, executors, successors and assigns, hereby completely and unconditionally release andagree to defend, indemnify and hold Hearts Going Towards Wellness (HGTW), InterAct Ministries Inc.(IMI), Severson/DePalatis Christian Counseling Center (SDCCC), Alaska Freedom Journey (AFJ), and LEaD Alaska; each of them, and their respective boards, officers, executive team members, leaders, presenters, employees, and other representatives, from and against any and all claims, costs, causes of action, expenses, judgments, and liabilities of any kind whatsoever resulting from, arising out of, or in any way relating to:
(a) My participating in the small group ministry at the Lazy Mountain, Palmer AK. facility
scheduled for October 21-25, 2015.
(b) Any counseling or small and larger group sessions in which I may be involved which use any
method’s or materials (including audio/video/cd/dvd/personal stories) developed by HGTW, AFJ, IMI, or SDCCC.
(c) My use of any information, methods or materials learned at or obtained through the smallgroup ministry or the Heart’s Going Towards WellnessConference; or
(d) The actions or omissions of any family members, including but not limited to minorchildren, and close personal friends who accompany me to the place where the smallgroup ministry is to take place, regardless of whether the family member or closepersonal friend participates in the ministry.
(e) I ______give permission to HGTW, AFJ, LEaD AK, IMI, SDCCC, (if the occasion arises), to use a photo of myself, in any publication or promotional materials.
Yes _____ No _____
PLEASE SIGN AND FILL IN THIS FORM BELOW.
Name(s):Signature:
Date:
Address:
City and State:
Zipcode:
Phone Number:
Signature of Witness:
Date:
Hearts Going Towards Wellness
Linda Ross Director
203 Linwood LN. Kenai AK, 99611-8114 phone/fax (907) 395-0633