2024-2025 SHIP registration and emergency form

Shamanic Healing Initiatory Process

From Friday at 7 p.m. to Sunday at 6 p.m.
SHIP Workshops 2024-2025

Cycles of Change: January 16-18, 2026Family of Origin: March 20-22, 2026Shadow: May 15-17, 2026Inner Beloved: July 31-August 1-2, 2026September 18-20, 2026
Date

MonthDayYear
Date
Name
also called
Street
City
Phone - Home
Cell
E mail
example@example.com
Relationship status
How long?
Children
Ages
Parents living
Ages
List significant others, including names, ages, and relationship
Age
Birth Date

MonthDayYear
Date
Birth Time
Birth Place
A brief summary of your birth process, if known: birth order, gestation--were you early or late?, what was the delivery like?, any other pertinent info?
Place of employment
How long?
a) Illnesses, injuries or surgeries
b) Any chronic illness
c) Level of education
d) Degrees, Certificates, Training (including domestic skills)
NOTE: Please write a short autobiography telling us a bit about yourself. Please include the challenges and important milestones in your life. Include your vision for your healing and training goals, why you are drawn to this workshop and what you hope to gain from this experience. This is confidential.
EMERGENCY INFORMATION FORM
In the event of an emergency of any sort, it is our wish to provide you with support and assistance. We ask that you help us by providing the following information. This information will be kept confidential.
Date

MonthDayYear
Date
Emergency contact name and relationship
Emergency contact home number
Emergency contact work number
Emeregency contact cell number
Are you currently under the care of a physician or therapist? names and phone numbers:
Recent surgeries or hospitalizations
Chronic illnesses
Known allergies
Please list any history of psychiatric treatment and hospitalizations
Prescription medications
Aahara Spiritual Community, 329 S. Douglas, Springfield, IL 62704 www.aaharaspiritualcommunity.org carleymattimore@gmail.com, johnmalan@gmail.com 217-494-0587, 217-494-0583
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Date

MonthDayYear
Date
Payment information
Donation: $425 per session Early Bird Discount: $375 or if you sign up for all 5 sessions together you can recieve the early bird discount of $1,875.00.

Note: A deposit of $100 is due with this application in order to reserve a space in the workshop, with the balance due at the beginning of the workshop. Space is limited.

Your donation includes workshop teachings and materials. You must arrange for a place to stay and meals separately. This workshop can be attended in any combination of sessions, only one or all.
Payment plans are available. Please contact us to discuss.

My deposit check or money order will be mailed.
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Shamanic Healing Initiatory Process

EMERGENCY INFORMATION FORM

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