EmailMe Form - GOLDEN BRIDGE 2018 PROGRAM APPLICATION

Name *

First Last

Phone

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International Phone

Preferred Email *

Confirm Email

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Personal Pronoun Preference:

Other

Date of Birth:

Month/day/year (ex. xx/xx/xxxx)

How did you learn about our program?

Please let us know who referred you to us or if you found us online or in print media...

GETTING TO KNOW YOU!

In order to understand your call to this work, your personal needs and individual inspirations, please respond to the following questions:

I AM APPLYING FOR

1. INTENTION:

Please share a brief intention that you are setting for this program.

2. WHAT IS CALLING YOU TO THIS PROGRAM?

Please briefly share a few of your passions and where you are currently putting your energy. What makes you, you? The highlights, a glimpse into what you are currently engaged in. Your current work? Are you in school? If so, where and what are you studying? Do you have a degree? If so, in what area of concentration? Are you working on a project? Are there causes or initiatives or programs that are shaping your life at this time?

3. BACKGROUND:

Please share any previous experience with Melissa. If you have not yet studied with her, please share any of your dance, somatic, or expressive arts background or training.

4. SPECIAL NEEDS OR REQUESTS:

Is there anything critical that you would like us to know about you? Challenges? Current life changes? Personal needs?

MEDICAL INFORMATION:

1. Please share any medical issues that could impact your participation in our program. (physical, psychological, other, including allergies)

2. Are you currently taking any medication? If so, please list and/or describe.

3. Are you pregnant?

YES

NO

4. Please provide any additional personal or medical information that will help us support you during this short but deep moving journey.

EMERGENCY CONTACT NAME: *

First Last

EMERGENCY CONTACT EMAIL: *

EMERGENCY CONTACT PHONE: *

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