Book your 1:1 Meeting With Holly and Toni
Name
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First Name
Last Name
Your Age
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Gender Title Preference (He, She, They or other)
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Phone Number
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E-mail
example@example.com
There will be both a farewell and welcome back ceremony and light meal in Upper Hutt. Your carers are invited to both these ceremonies which will be at 5.30pm. Please share the names of the people who will be at the ceremonies and a contact email and phone no for them.
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Please share two emergency contact names and their phone numbers and email contact. This is so we can contact them on your behalf if there is an emergency situation.
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Please tick the items you dont have that you will need to borrow
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Tent
Two 1.8x1.8m tarps
Camp Mattress
Sleeping bag
Liteweight Camp plate
Liteweight Camp Mug
Liteweight Camp cutlery
Two 2 litre Water Cotainers for drinking from
12m of 5mm diameter rope for tying your tarp to trees
A suitable pair of hiking or walking shoes
A pair of liteweight sandals or similar
Raincoat and leggins
A sunhat
Sunscreen
A liteweight pillow
A two person or 1 person tent
Head torch
Towel
An Item of Intention (Something that represents your journery through life to this point. An natural object like a stone or shell that can be left on the land.
Participants declare that they currently have no legal or non-legal dependence on any addictive substances. This includes prescribed medication such as opiate-based pain relief.
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Please Select
Yes
No
I need to share details with Toni and Holly
Participants agree that they will share with Toni and Holly and prescribed or non-prescribed medication for mental health such as anti-depressants, or antipsychotics that they are on. They agree that they will seek medical advice in regards to fasting and the medication they are on, and share that advice with Toni and Holly.
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Please Select
Yes
No
I need to speak with Toni and Holly about this more
Participants agree to no Smoking or vaping while on the program, you may use nicotine patches if needed.
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Please Select
Yes
No
All criminal convictions or pending upcoming court proceedings must be declared fully in the 1:1 meeting with Holly and Toni. Note there will be no legal consequences as a result of sharing these details.
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Please Select
I agree and have convictions to declare with Holly and Toni in my 1:1 Interview
I agree and have no convictions to declare
We would like to respectfully take some photos of different aspects of the program for future program promotion. Are you comfortable with being in those photos and for us to use those for program promotion only?
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Please Select
Yes
No
Maybe I will share details in the 1:1 with Holly and Toni
Please share any concerns or fears you have about participating in this program
Signature
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Appointment
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