Application Form 1: Personal Details Name * First Name Last Name Date of Birth MM DD YYYY Gender Female Male Other Rather not to specify Occupation (most recent) Mobile Number (###) ### #### Email Postcode 2: Personal History Thank you for sharing details of your medical history so that I can be prepared to give you necessary help and support. How would you describe your symptoms/issues, when did they begin & how do they affect your life? To help me assess your suitability for the seminar, please tell me if you have any medical or mental health issues that you have not yet mentioned on this form: Do you know of someone who has used the Lightning Process to recover their health? Yes No How did you hear about Jodie and the Lightning Process? How would you like to take the seminar? Via Zoom In Person Please tick if you would like to bring a support person. (A support person is an individual who attends but does not complete the training course. There is no extra fee for your support person). Yes, I would like to bring a support person with me. 3: Application Questions Do you feel you can influence your health? Yes No May be Do you believe you can get better/resolve your issues? Yes No May be How do you hope to feel when you have resolved your issues? e.g. More energized, more focused etc. (please list at least 4 things): When you resolve your issues, what would you love to do with your life? e.g. Start my own bz, run a marathon etc. (please list at least 4 things) : 4: Confidentionality Do you agree to maintain confidentiality with information shared by others during the training Yes 5: Terms & Conditions If you are under 18 your parent or guardian will need to read and accept the Terms and Conditions on your behalf. Agreement I have read and accepted the Terms and Conditions Name (of participant, parent or guardian), signature and date As a parent or guardian, what is your relation to the client? I would like to have my attendance certificate logged with the Lightning Process Head Office: Yes No I wish to receive occasional and relevant correspondence about developments in the Lightning Process: Yes No I give my permission to be contacted at regular intervals to monitor my progress for the purpose of further research into the Lightning Process: Yes No 6: Emergency Contact So that we can contact someone closet to you in the case of an emergency please provide: Emergency Contact Name Emergency Contact Cell Number Thank you for your application form and well done for taking the next step in your healing journey. I will be in touch soon to arrange a time for us to chat.If you have any questions, please feel free to reach out.Kind Regards,Jodie Please read the Terms & Conditions before filling out this form
