Adult Program Registration Step 1 of 425%Your healing program booking will be confirmed once we have received:1. your registration form and2. your initial registration fee or payment.To avoid disappointment, PLEASE only make travel or work arrangements after you have received your confirmation.Before you can continue the registration process you must read and agree to our key safety principles. This is to ensure that Heal For Life is a safe place for everyone. Please contact us if you have any questions.KEY SAFETY PRINCIPLESSafety is the essential foundation of the success of a Healing Week. Safety for the group is the first priority. It is vital that each person in the group, including the Support Team, understands and agrees to uphold the following principles. A breach of these principles can result in eviction from the Healing Week. You will be invited to return to HFL when you are able to uphold the principles.I agree to: 1.Keep totally confidential the identity and stories of other people I meet, including when I return home. This will help me and others feel safe to be vulnerable and honest so we can heal. 2. NOT bring any alcohol or illicit drugs to the Healing Week or arrive at the property under the influence of alcohol or illicit drugs. If you have a history of drug or alcohol addiction we ask that you are ‘clean’ for at least a month before your visit so you can feel your feelings, stay grounded and have no possibility of withdrawals during the Healing Week.3. I agree to remain on the property throughout the Healing Week. Every day of the program for guests is vitally important. Having a break from the program, even for medical reasons, is disruptive and can distract you and your fellow guests from healing. Exception: Members of the Support Team may leave the property when they are off-duty for personal time-out to self-care. 4. Refrain from sexualised behaviour. So that everyone can feel safe and focus on their healing, nudity or partial nudity; sexual activity; kissing; flirting; sexual jokes or innuendos are not appropriate during the healing program. Sexual behaviours also include any talk, touch, questions, conversations and interests which relate to sexuality and relationships. I agree that if any private sexual matters arise related to my healing I will discuss with a Support Team member and not other guests.5. Commit to my healing and avoid distractions. It is important to be here for you and not to satisfy family members or others. It’s vital to avoid distractions so that you and your fellow guests can receive the maximum benefit from the week. For this reason there are no TVs, newspapers, radios, magazines or games. I agree to not bring fiction novels, electronic devices, laptops or any usual work or study, TVs, newspapers, radios, magazines or games. Please refrain from talking about topics unrelated to healing.6. Participate in all aspects of the program and be part of a group. We have found that being a part of the group is a vital factor in your healing process. It is absolutely vital that all members of the group work together peacefully and lovingly and take full responsibility for their part in any conflict.7. Not keep or use my mobile phone during the week. Using a mobile phone can break the sense of safety for everyone and distract you from your healing. We will ask that you leave your mobile phone in our care during the week. Of course, if there are exceptional circumstances, you can be contacted or contact people via the office during the week but please discuss your communication needs with the Facilitator before the week begins. Exception: Support Team Members may make personal calls from inside the Team Cabin.8. Not self-harm. Self-harm is a way some of us abuse ourselves, however, HFL is not a medical facility. Our healing program is designed to help you develop alternative, effective coping mechanisms. I agree to speak with a Support Team member if I have thoughts of wanting to self-harm.9. Behave in a safe manner. In order to create a safe place, abuse of any kind is not tolerated. This includes swearing or shouting at someone, derogatory comments or using intimidating body language .Name* First Last I agree with all of the above safety principles* Click in the box to indicate yes you agree and click Next to continue your registration If there are any cultural or religious observances you adhere to, please speak with the facilitator on arrival to the program. Please complete all of the items below so we can provide the best possible service to you. PLEASE NOTE: Boxes and questions marked with an asterisk (*) must be completed to continue.Date of Birth* DD MM YYYYAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Alternative PhoneEmail* Gender*Please select...MaleFemaleDo you have children?*YesNoHow old are they?Are you Aboriginal or Torres Strait Islander Origin?*YesNoOccupation*Is this your first healing program with Heal For Life?*YesNoHas a member of your family done a healing week?*YesNoHow did you find out about Heal for Life Foundation?*Please select...TVFamily/FriendsPhone BookWeb SearchBrochureRadioSeminarNewspaperSocial Media (Facebook, Twitter, etc)OtherHow will you travel to your program*Please select...CarPublic TransportNominated EMERGENCY CONTACT PERSON to be contacted if you leave before the end of the program or in an emergency.Name* First Last Relationship to you*His / Her Phone Number*His / Her Alternative Phone Number*Have you had a drug / alcohol / gambling issue?*YesNoPlease specify* Alcohol Illicit drugs Non-prescription Medication Gambling OtherOther - Please Specify*Have you been clean for 30 days?*YesNoWill you be taking medication during the program?*YesNoPlease list all of your medications, their dosages and the times you need to take them*Are you a heavy snorer?*YesNoIf YES, you may be asked to sleep in a more private area.Do you smoke?*YesNoIf YES, there are designated smoking areas and NO smoking during workshopsAre you pregnant?*YesNoHow many weeks?Can you swim?*YesNoThere is a dam near the adult centreDo you have any allergies or specific dietary needs?YesNoPlease specify Vegan Vegetarian Lactose Intolerant Diabetic Coeliac Food Allergy OtherFood Allergy - Please SpecifyOther - Please Specify*If you feel it would be helpful for us to know, please note any mental health diagnoses or physical impairments Depression Anxiety PTSD Bipolar ADHD Dissociative Identity Disorder Schizophrenia Borderline Personality Disorder Obsessive Compulsive Disorder (OCD) Other Physical impairmentsOther - Please Specify*To enable us to help you better, you may wish to let us know the type of trauma you are a survivor of: Physical Emotional Sexual Domestic Violence Bullying Neglect Abandonment Poor Parenting Spiritual Incest Divorce of parent Death of a parent and/or sibling Early Childhood Illness Child in State Care Child Refugee SRADo you have any phobias/fears that you feel it would be best we know about?*YesNoPlease specify:*Is there anything else about your current circumstances that might be useful or helpful for us to know?*YesNoHave you previously used the services of Health Professionals?*YesNoAre you currently seeing a Health Professional?*YesNoPlease specify:*Please note down what your goals might be for the week, eg what would you like to change about yourself or your life by attending the program?* Your healing program will be confirmed once you have sent your Initial Registration Fee.PLEASE do not make any travel or work arrangements until you have received a letter or email confirmation from us.Cancellation / Deferral:We often have a waiting list for our programs. If you cancel, defer or do not come to a confirmed place this may prevent someone else from attending. Please tick that you have read and understand the following:1. I accept that if I cancel or defer after confirmation has been received, my Initial Registration Fee is not refundable.2. If I cancel/ defer within 7 days of the program start date I understand that I am committed to complete the payment option I have chosen as it will have prevented someone else from attending.3. If I choose to leave the program or if I am asked to leave prior to its completion I understand that I am committed to complete the payment option I have chosen.Date of the Program you wish to attend*2nd-7th Feb 202022nd-27th March 202019th-24th April 2020Yes* I have read and understand the above cancellation/deferral details. The following fee covers accommodation, all workshops and workshop materials during the program. Heal For Life is committed to making our program available to anyone in need regardless of current income. However we receive no Government funding and we wish to remain independent. We are very grateful to those who can afford to pay the whole fee.We offer monthly payments to make it easier for you. If however you have any problems with any of these options please call us on 02 4998 6003.The following fee covers 5 nights’ accommodation and all workshops during the program. We wish to keep our program as affordable as possible and trust you will opt to pay the fee that best meets your financial situation.Centrelink NumberPayment Options*Please select...Upfront Payment ($1,200)Call to discuss payment optionsPlease contact the Heal for Life office directly on (02) 4998 6003 to organise payments.Thank you! This iframe contains the logic required to handle Ajax powered Gravity Forms.