Vibravision Program Application for Justin & Jackie

Vibravision® Program Application

(please provide a brief answer to ALL questions if possible, or "not applicable")
1. Background
Full Legal Name*
Name you prefer
DOB*
Phone*
Email*
Employer
Occupation
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Which Immersion Date are you interested in attending?*
How did you initially hear about us?*
If you were referred, who referred you?
2. Health Information
Vibravision involves moderate exercise, sitting and standing for a long period of time, and basic body movements. Are you comfortable with these requirements?*

YN
Do you have any of these conditions? (Please check all that apply.)

StrokeHead InjurySeizuresPacemakerHeart ProblemsHigh Blood PressureAllergiesIBS or Crohn'sPersonality Disorder (eg. Multiple Personality Disorder, Schizophrenia, Bipolar Disorder, etc.)
Are there any other medical conditions that we should know about?*

YN
If yes, please explain:
Emergency Contact Information:
Name*
Phone Number*
Please enter a valid phone number.
Relationship*
3. Mental

*Note: As the safety of our participants is our top priority, and decades of training have shown that the severity of certain disorders may be accentuated with our (and other energy work training methods), it is very important that this question is answered completely and truthfully.
Have you ever been diagnosed with any mental health disorder such as Schizophrenia, Multiple Personality Disorder, Oppositional Defiance Disorder, Bipoloar Disorder, etc.?*

YN
If yes, please explain
Ever hospitalized for mental breakdown or illness:*

YN
If yes, please explain:
4. Legal
Have you ever been convicted of a violent, fraudulent, financial, or sex crime?*

YN
If yes, please explain in detail:
5. General
What is your experience with various energetic practices?
What questions do you have about Vibravision?
6. Notification and Authorization to Access Background Check and Behavioral Information
Notification

The program for which I am being considered requires me to consent to a criminal background check, ID verification, and behavioral review using the SafetyPin service as a condition of acceptance into any Vibravision® program.

Authorization

I hereby authorize Vibravision® to conduct the criminal background check, ID verification, and behavioral review mentioned above.

Receiving your Safety Pin is easy, but there are some steps to follow:

1) Make sure you have your ID, Social Security number, Credit Card, and TSA Known Traveler Number (if you have one) handy when filling out the Safety Pin form. Please make sure to double-check everything, as misspelled or inaccurate information may cause your application to be declined.

2) When you receive a link to SafetyPin in STEP 4, at the end of this application process click APPLY NOW. Once you've filled out all of your information, there will be a $1 fee that you will need to pay, and Vibravision® will take care of the remaining balance on our end for your first full year of Safety Pin monitoring and membership.*

*Note: Any current or previous residents of New York will be charged an additional, required, one-time, non-refundable fee of $95 for a county background check. The totality of those funds goes to the state of New York to run any reports in their jurisdiction.

3. In the next step of this application, you will schedule a call with our Admissions Advisor for 7-10 days from this application submission. You will have an opportunity to discuss the SafetyPin investigation on this admissions call.

4. Now, you will have your own SafetyPin badge that you can display online on any profile to let the world know that you’re a safe individual, and will take the next step toward approval for Vibravision® training.

Note: A person’s SafetyPin is monitored to ensure that a person should continue to earn the SafetyPin badge. If a participant’s SafetyPin is revoked, they will be denied access to any future Vibravision event.

*For International / non-U.S. citizen applicants: SafetyPin only provides background checks for U.S. citizens. Conducting an international background check for non-U.S. citizens will require the usage of a different company, and may incur additional charges to complete. Please submit this application and you will be contacted shortly with directions on the next step.
7. Confidentiality Agreement and Waiver of Liability
I understand that I will be required to sign a Confidentiality Agreement and Wiaver of Liability prior to the start of the Immersion and a condition of attendance.
8. Certification
I hereby certify agreement to all terms of participation in Vibravision immersions stated in this application and that all of the above information given is true and correct to the best of my knowledge. I understand that any falsification or omission of information may disqualify me from this or other Vibravision® programs.
Attendee Printed Legal Name*
Date*

MonthDayYear
Date
Signature

Clear
Parent/Guardian Signature (if client is a minor)

Clear
Client/Guardian Name
By signing, Parent/Guardian authorizes and agrees that they will be bound by the terms of this agreement on behalf of the minor listed above, and responsible for said minor's adherence to it, and all terms set forth.
Address for legal notices to Vibravision: Vibravision®

Attn: Nate Zeleznick or Mike Zeleznick

P.O. Box 328 Huntsville, UT 84317 USA
NEXT STEPS: You will receive a payment form and be contacte to scheduled a welcome call.
Should be Empty:

Vibravision® Program Application

6. Notification and Authorization to Access Background Check and Behavioral Information

7. Confidentiality Agreement and Waiver of Liability

8. Certification