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Prayer Ceremony Registration
Must be submitted 10 days prior to arrival. Please do not submit this form until you are fully committed to the date and donation required to attend.
Please select the ceremony you wish to attend.
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Please Select
Amor Agape - Sep 26-28
Four Altars - Nov 7-9
Mens Retreat - Oct 10-12
Women’s Retreat - Oct 17-19
Date specifics can be discussed after submitting your registration. (ex. Private ceremony, daytime only, etc.)
Are you currently a registered member of Agape Church for Soul, Mind & Body? (You have completed the new online application and have received confirmation of your membership.)
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Yes
No
Member Information
Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Date
Email
*
example@example.com
Contact Phone Number
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Please enter a valid phone number.
Are you currently a contributing member of the Ayni Program?
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Yes
No
Are you a member of the Armed Forces, Veteran, Front Line Healthcare Professional, or First Responder?
Check if YES
Emergency Contact Info
Name
*
First Name
Last Name
Emergency Phone Number
*
Please enter a valid phone number.
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Medical Disclosure
Please complete the following questions truthfully and accurately, as results of misinformation may result in injury or death.
Please check all that apply to your past or current medical diagnosis. If none, select "No Preexisting or existing medical conditions". If not listed, select "Other" and explain.
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Terminal Illness Diagnosis
Psychiatric, Mental or Emotional diagnosis
Substance Abuse Issues
Addiction
No preexisting or existing medical conditions
Alcoholism
Paralysis
Cardiovascular Disease
Diabetes Type I & II
Post Traumatic Stress Disorder
Other
Please check all that apply to your current prescription medications, including within the last 90 days (if not listed, select other and explain):
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Monoamine oxidase inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitor (SSRIs)
Amphetamines
Cannabis
Mood Stabilizer
Not Applicable
Antibiotics
Other
Do you have any allergies? (including food, drug, latex, mold, pollen, pet or insect)
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Yes
No
If yes, explain.
Do you require assistance from medical devices or personnel? (including but not limited to asthma inhaler, CPAP, oxygen machine, wheelchair, etc.)
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Yes
No
If yes, explain.
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Acknowledgements, Hold Harmless & Waiver of Liability
Your signature is required prior to submission. If you have any questions regarding this form, please contact a representative of Agape Church prior to submission.
During the entire process of completing this registration form, I have been and am currently of sound mind and body, acting in my own faith and best interests without duress or undue influence.
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I confirm and understand the statement above to be true and accurate.
I understand that my participation in ceremony with Agape Church and Healing Center for the Soul, Mind and Body is solely for religious and/or spiritual purposes.
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I confirm and understand the statement above to be true and accurate.
I understand that any false statements provided within this application could result in serious injury or death of myself and/or other participants, and I take full responsibility for the information I've provided within this form.
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I confirm and understand the statement above to be true and accurate.
I am a consenting adult of sound mind and body. I have voluntarily, without duress or undue influence, chosen to partake in a “plant-based” and/or "animal-based" ceremonial sacrament ritual held by Agape Church for Soul, Mind and Body (a non-profit faith-based organization 508c1a organization) for spiritual and religious purposes. I am acting out of faith, and faith alone in communing with these sacraments in ceremony. I am aware of the risks and, by affixing my consent below, waive all liability for the sacrament officiant(s), his agents, and associations into perpetuity.
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I confirm and understand the statement above to be true and accurate.
Signature
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Submit
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