Awakening of Love & Introductory Work Application Form

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Select the event you're
applying to *
First Name *
Last Name *
Preferred Name
Gender *
Date of Birth
(DD/MM/YYYY) *
Occupation/Profession *
Street Address *
Suburb/City/Town *
State/Province/Terr/Region
Postal/Zip Code *
Country *
Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number(s) *
In what language(s) are you
fluent? *
English
German
Italian
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Portuguese
French
Hebrew
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Other
If other was selected, which one?
Are you interested in receiving our newsletters via e-mail? *
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How did you hear about this workshop? *
Please list the personal growth work you have participated in including therapy groups, spiritual retreats and individual therapy. *
Briefly write about why you want to do this workshop? *
Do you have any physical disabilities or limitations due to injuries, surgery, congenital conditions, disease, or condition (such as allergies or pregnancy)? Please let us know of any health or medical issues that are important for us to know about. *
Are you being treated, have you ever been treated, or have you experienced (currently or in the past) any mental or nervous condition, including mental or emotional illness, personality disorder, addiction, anxiety, depression, or suicide attempt? Are you taking any prescription medication? If so, please give details. *
Is there anything else that relates to your physical, emotional or mental health that is important for us to know and that this questionnaire does not address? *
Anything else you would like to share? *
I represent that all of the information provided in this Application is true and correct to the best of my knowledge, and is being relied upon by POL Global Foundation Ltd in deciding my acceptance into this Awakening of Love and/or Introductory Work process.

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