Registration Form – Wellness Through Living

Name *

First

Last

Date of Birth *

Number of Dependents *

Were you referred to us by a community agency? (For example: a doctor, counsellor, treatment program, court, etc.) *

Yes
No

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have any medical conditions or history that would interfere with the program during the 15- weeks? *

Yes
No

Are you currently taking any medications? *

Yes
No

Do you have any allergies? *

Yes
No

Emergency Contact # 1: Name *

Emergency Contact # 1: Phone *

Emergency Contact # 1: Relationship *

Emergency Contact # 2: Name *

Emergency Contact # 2: Phone *

Emergency Contact # 2: Relationship *

Participant Agreement

1) Remember what is said by other participants doesn't leave the program, all information is private and not to be shared outside of the program. *

I agree
I do not agree

2) Please do not gossip about other participants inside or outside of the program *

I agree
I do not agree

3) Please either turn cell phones off or on silent. If you are expecting an important phone call, please let the program staff know and take the call outside of the room. If phones are deemed a distraction, the program staff may ask you to no longer have your phone with you or ask you to give your phone to the program staff for the day.

I agree
I do not agree

4) The program will start at 8:30AM and end at 3:30PM every day, please be on-time and prepared to stay for the entire day. *

I agree
I do not agree

5) Please be aware of how you are talking, for example your tone or choice of words (swearing is not allowed during the program). This also includes allowing others to have a chance to speak and not having side conversations when others are talking. *

I agree
I do not agre

6) Please remain in the room during the entire, there will be breaks. If you need to step out, please let the program staff know. *

I agree
I do not agree

7) Please be aware of other participants boundaries, physically, mentally, emotionally, and spiritually. We all have different boundaries so we all need to be respectful. *

I agree
I do not agree

8) Please be aware of your hygiene and body odors, other participant maybe be sensitive to certain smells, this includes perfume/cologne and cigarettes smells. *

I agree
I do not agree

9) If you no longer wish to be a part of the program, you must let the program staff know and they can process your departure from the program. *

I agree
I do not agree

10) The program facilitators can use their discretion and discharge anyone from the program if they deem it necessary and appropriate. This could be for the day or for the remainder of the program. *

I agree
I do not agree

11) Abusive and threatening language and/or behaviour will not be tolerated. You will be asked to leave for the remainder of the program if the program staff feel like you are a risk to others. *

I agree
I do not agree

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