Registration Form

Registration Form
Dear Friend:

The Voice in the Wilderness Mission would like to thank you for choosing our program to assist with your health needs. Our program has been designed to help in the health and healing of the whole person. Our goal is to teach you the causes of disease, its prevention, and its cures. Education is the key to good health and our Ten-Day Cleansing Program is designed to provide you with a broader awareness of what constitutes good health and how to maintain it.

Our accommodations are home-like and simple, yet clean and comfortable. Don’t forget to leave the stress at home and come to relax and enjoy!

What to Bring

The following items are things you will need to bring with you for your stay with us. Please bring warm comfortable clothing enough for ten days (Even during the summer months the morning temperatures tend to be cool in the mountains), water shoes, a bathing suit (for steam bathing), a warm or heavy robe, shower cap, warm night wear, any personal items, flashlight, pen and notebook, and any personal reading material or craft.

SORRY! NO PETS ALLOWED!

Please fill out the information required on this registration form to enroll in a scheduled Ten-Day Cleansing Program. When this form is completed, please mail it to The Voice in the Wilderness Mission, 173 Bush Road, Savoy, Massachusetts, 01256. Or fax to: 508-635-9651.
Personal Information
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

City or Town: State:

Zip:
Phone: (Home)
Please enter a valid phone number.
Phone: (Work)
Please enter a valid phone number.
(Cell)
Please enter a valid phone number.
Email Address:
example@example.com
Age:
Date of Birth:

MonthDayYear
Date
Sex:

MaleFemale
Relationship Status:

MarriedSingleDivorcedSeparatedWidowed
What type of work do you do?
Religion: (If any)

Financial Information
What payment method will you be providing?

CheckCredit CardCashDebitMoney Order
Total amount due:
Total amount due:
Credit Card Information:

DISCOVERMASTER CARDVISAAMERICAN EXPRESS
Card#
Exp. Date

MonthDayYear
Date
Security Code
Authorization Signature:

Clear
Please call to verify your program package price.

Arrival & Transportation Information
Program arrival date:

MonthDayYear
Date
How will you be arriving?

CarBusTrainPlaneOther

Pick-ups from the below listed locations are an extra fee

	$
Springfield Train Station
Albany Airport & Train Station
Bradley International Airport in Hartford, Connecticut
Pittsfield Train or Bus Station

Call for updated pricing. Prices subject to change without prior notice. Prices are one-way and are to be paid directly to the driver. Prices do not reflect a tip.

To schedule a pick-up from Uber or Lyft.

UBER.COM or LYFT.COM

Application Details

Upon returning your application, it is important that you include a deposit (1/3 of total fee). We cannot guarantee any reservation without a deposit, and reservations are not confirmed without your deposit. Deposits are non-refundable, but may be applied to a rescheduled program within a four-month period. The remainder of your balance must be paid upon arrival. We do not provide payment plans. Sorry. If you have any questions or concerns please feel free to call us at this phone number during office hours, 9 am- 1 pm. 413-743-9743. The best time of the day to register is before noon.

Trust in God’s Power
“And the peace of God, which passeth all understanding, shall keep your hearts and minds through Christ Jesus.” Philippians 4:7

“I can do all things through Christ which strengtheneth me.” Philippians 4:13
Do you believe in God?

YesNo
Are you developing your mental and spiritual capabilities by daily Bible study andprayer?

YesNoInfrequently
Do you frequently experience worry, stress, or anxiety over life’s difficulties?

YesNo

Thank you for taking the time to fill out this form.
CONSENT FORM FOR NATURAL THERAPIES
I, , whose current address is herby
authorize The Voice In The Wilderness Mission, its hygienic practitioners, staff assistants,
volunteers, and other attending personnel associated with or designated by them to admit me to
their natural therapies program and treatment facility located at 173 Bush Road in Savoy,
Massachusetts, and I herby record my consent for the same to perform upon me such diagnostic
procedures and such natural therapeutic procedures involved in the (check appropriate box) 3 Day program, 5 Day program, 10 Day program as they, in exercise of professional judgment, decide are necessary for my continual treatment and care. It is my intention to consent not only to such procedures which have been anticipated, but to such further diagnostic and other natural therapeutic procedures which may become necessary or deemed advisable in the professional judgment of the Hygienic practitioner and other attending personal and as my treatment care continues.
The nature and purpose of the procedures, and expected discomforts, risks, complications, and
benefits, if any have been fully explained to me. I am aware that the administration of natural
therapies is not an exact science and results cannot always be anticipated. I also acknowledge that
no guarantees or assurances have been made to me concerning the results from the procedures. I
recognize that it is my responsibility to fully disclose to my attending hygienic practitioner any
physical or emotional conditions and medications currently taking or recently taken which may be
detrimental in any way to the success of the natural therapy procedures or to my ultimate recovery.
I also understand that any medications that I am currently taking, is my personal responsibility to
continue to dispense, and take as prescribed by my medical doctor. And any discontinuance of this
medication regiment is my personal decision and choice and I will assume all responsibility for any
negative effects this may have upon my health.
I have been given the opportunity to ask questions and all of my questions have been answered
fully and satisfactorily.
This consent is not only to the hygienic practitioners, staff assistants and other attending personnel
of The Voice In The Wilderness Missions to whom I have entrusted my care, but to others
associated with or designated by them. In granting this consent, I intend to assume the risk of
possible unforeseen results and to be legally bound.
I agree not to revise, limit or alter this legal consent except in writing.
Signature of patient

Clear
Date:

MonthDayYear
Date
If patient is unable to sign or is a minor, complete the following: Patient is a minor years of age or is unable to sign due to,
Signature of parent, legal guardian or person authorized to sign.

Clear
Should be Empty:

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Registration Form

Personal Information

Financial Information

Arrival & Transportation Information

GENERAL HEALTH INTAKE

Health Information

Medication & Nutritional Supplement List

Nutrition & Dietary Information

Physical Activity

Water

Sunlight

Temperance

Air

Rest

Trust in God’s Power

Social & Family Relationships

Emotional Health

CONSENT FORM FOR NATURAL THERAPIES

	Food Item	Allergic Reaction
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