WIID Certification Program Application Form

WIID Certification Program
Thank you for your interest in applying for the WIID Certification Program!

APPLICATION FORM
Full Legal Name*

First NameMiddle NameLast Name
Birthday*

MonthDayYear
Date
E-mail*
example@example.com
Mobile Phone*

Country CodeArea CodePhone Number
Country of Residence*
Which certification program are you interested in?

BEinShape Rescue Level: Stress and Fatigue ManagementEnergy Management for Depression and AnxietyEnergy Management for Cancer and Side Effects of Medical InterventionEnergy Management for Stroke and Heart Diseases
Who recommended you? How did you find out about this program?
Why do you want to join this program?*
Personal Information
Marital Status
No. of children and their ages
Languages you speak and write fluently in:
Religious/spiritual affinity
Organizational affiliations, membership of clubs, associations, etc.
Volunteer activities and social service
Employment
Occupation/Career
Do you have any experience in any of the following?

YogaMeditationHealingCoachingMentoringPublic SpeakingMedicineAlternative/Complementary MedicineOther
Please write down any other practices you do or skills you have that are not listed above. Please also provide details of your experience in the fields you checked above.*
What are you hobbies and talents?*
What are your greatest strengths?*
What are your greatest weaknesses?*
Tell us about a challenging moment in your life and how you overcame it.*
Tell us about your most meaningful success or achievement in life.*
Who have been your role models, teachers, mentors or people of influence in your life and why?*
Please describe a typical day in your life.*
Please share your experience of working in a team and any challenges and successes you had.*
Please share your experience of leading a team/project and any challenges and successes you had. *
What is your life's ambition or purpose?*
What do you hope to achieve from this program?*
Tell us about your Overall Health and Habits
Do you consume*

TeaCoffeeTobaccoAlcoholPrescription DrugsRecreational DrugsNone of the above
Does your diet include*

BeefPorkChickenSeafoodVegetablesDairy ProductsI am vegetarian/veganOther
Specify any recreational or prescription drugs you are taking here
How often do you exercise?*
What exercise/s do you do?
What is your weight goal?
My current weight is:
Physical Health Status*

High Blood PressureLow Blood PresureHeart DiseaseAsthmaSpinal IssuesCancerDiabetesAnemiaBleedingInternal OrgansAddictionLearning DisabilitiesEpilepsyVertigoMigraineInfertility/ConceptionPeri-menopauseMenopausePainFatigue
Please list down any other conditions you have that are not listed above.
Do/did you have any major health issues?

Total Health Status - Rate yourself on a scale of 1 to 5 (1 is Poor and 5 is Excellent)*

	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Physical Health
Vitality and Energy Level
Emotional Stability
Mental Attitude and Clarity
Religious/Spiritual/Inner Alignment

General Quality of Life - Rate yourself on a scale of 1 to 5 (1 is Poor and 5 is Excellent)*

	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Relationships at Home
Relationships at Work
Social Relationships
Job/Role Satisfaction
Quality of Rest/Relaxation
Ability to Manage Stress
Quality and Time for Recreation
Financial/Material Life
Level of Success
Level of Self-Fulfillment in Life

Psychological Status*

	Yes	No
Fear/Phobia
Anger/Frustration
Anxiety/Worry
Sadness/Loneliness/Grief
Guilt/Self-Pity
Resentment/Pent-up Emotions
Lack of Self-Confidence/Self-Esteem
Laziness
Lack of Motivation/Purpose
Slowness in Action/Indecisiveness
Psychological Depression
Suicidal Tendency
Self-Destructive Behavior
Anti-Social/Oppositional Tendency
Vice/Addiction
Compulsion/Obsession
Trauma/Post-Traumatic Issues
Shame
Abused/Victim
Abuser

Please describe any other psychological issues you may have or give additional information related to the items you have checked above.
Please upload your recent picture*

Full body picture is preferable
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DISCLAIMER/WAIVER

I understand that World Institute for Incurable Diseases (WIID)TM and the WIID Online Certification Program application is private and confidential and all the information I have provided herein will not be shared with any third parties without my consent.

I attest that everything I have written here is true and correct.
Signature*

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Date of Application*

MonthDayYear
Date
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WIID Certification Program

Personal Information

Tell us about your Overall Health and Habits