EmailMe Form - YOUTH ON FIRE TRAINING 2018 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:

1. INTENTION:

Please share a brief intention that you are setting for this program. Your personal intentions are as important as your professional ones.

2. WHAT IS CALLING YOU TO THIS PROGRAM?

Please share a bit about your relationship with youth development, rites of passage, somatics, or other works related to this training. Are you professionally engaged in kindred work? If so, please describe the context and the nature of your work. If you are a parent or youth, please share anything you would like us to know about why this program and why now in your life. What are the questions, aspirations, goals you have for your professional development during Youth On Fire?

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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