Medical history and screening

Step 1 of 8

As part of my application to participate in the One Light Tribe meditation circle, I am completing this confidential Medical History and Screening Form in order to support the groups efforts to ensure the safety of myself and those others participating. The information provided on this form will be kept used by the organizers to determine the appropriateness of my participation.

I understand that this gathering is a Spiritual and Religious undertaking and while great personal growth can occur, the experience should not be considered a substitute for medical treatment or psychotherapy. It may not be appropriate for those with certain medical conditions, those diagnosed with mental illness or for those using certain medications.

Name(Required)

First Last

Gender(Required)

Address(Required)

Street Address City Country

Date of Birth(Required)

Phone(Required)

Email(Required)

Emergency Contact Name(Required)

First Last

Relationship(Required)

Emergency contact phone(s)(Required)

Medical history and screening

Please answer ALL of the following questions as completely and honestly as possible. Select “yes” or “no” as applicable. Please elaborate on any “yes” answers. Your responses will remain strictly confidential.

Do you use any of the following:

Please return this form to complete registration. All information will be kept confidential.