Oneness Awakening Course Application

Applicants Name Street Address City State Zip Code Home phone Cell phone Email address Course Dates: Jan 25 and 26, 2014 Course Location: Andy's home in Boxborough, MA Course Fee (please check): ____$195 (paid by Jan 11th) ___$215 (paid after Jan 11th) ____$125 (Oneness Blessings Givers only) ____Free to Oneness Blessing Givers who bring someone new ______________ (name) If you did not pay electronically on Eventbrite, please make checks payable to Andy Migner 1. Have you received the Oneness Blessing? _____ 2. How did you hear about this course? 3. Are you currently using or have you used within the last 6 months any medications for any mental health problem? _________ 4. Have you ever been institutionalized for a mental health problem? _______________ 5. Have you ever been diagnosed with a mental health problem? ______________ If so, please describe the problem? 6. Are you challenged by substance dependence or abuse? If so, which substances and how regularly do you use them? I hereby state that all of my answers to the questions contained in this application are true, correct and complete. __________________________________ Applicants Signature If not mailing with payment, you may e-mail registration form and application toandy@mayallbepeaceful.com