PROGRAM Application
Complete this form to apply for an upcoming program and ceremony.
Name
*
First Name
Nickname
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Prefer Not to Say
Tell us about yourself. I am a
*
Veteran
First Responder
Active Duty
Gold Star Spouse
White Star Spouse
Spouse (Current or Ex)
Adult Child
Adult Sibling
Civilian
What branch of the Military or First Responder Group?
*
Current occupation?
*
Are you the spouse or direct family member of a person that has attended a wellness retreat hosted by The Illuminating Co.?
*
Yes
No
Have you ever used sacred plant medicines before? (ceremonially or recreationally)
*
Yes
No
If yes what was your experience? (positive/negative)
*
Do you have any spiritual or religious practices including church, prayer, meditation, yoga, breath work, acupuncture, or any other practice?
*
Please describe your current mental state. Please be honest and specific.
*
If you served in the military or first responder please upload a copy of your DD-214 of first responder Certs. If you are a spouse or family member please provide your veteran or first responder family members credentials.
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If you served in the military and you received an other than honorable discharge or bad conduct discharge please explain your circumstances.
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
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