Power Breath for Military Leaders April 9-11,

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The International Association of Human Values ( www.IAHV.org) is a non-profit educational and humanitarian foundation that has provided stress management, humanitarian and trauma-relief programs in the United States and worldwide in areas of trauma, conflict, and natural disaster. THIS FORM WILL BE KEPT CONFIDENTIAL

Email *

Power Breath for Military Leaders - a program of Project Welcome Home Troops

First Name *

Last Name *

Address

City *

State *

Zip code

Home Phone

Cell Phone *

Work Phone

Emergency contact and phone *

Occupation

Date of Birth

YYYY

Sex *

Participant Designation *

Branch of Military Service (only Veteran need respond)

Active Duty

Rank

Deployment information (optional)

How did you hear about the course?

Briefly describe your mental and physical health *

Please indicate if you have any of these conditions: *

Asthma

Diabetes

Emphysema

seizures/Epilepsy

Heart Disease

Stroke

Bi-polar

High Blood Pressure

Depression

Anxiety / Panic disorder

Traumatic Brain Injury

Pregnancy

NONE

Required

I am available and understand that I must attend all sessions during this course

Yes

Other:

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If you are you presently under the care of a physician, or psychiatrist, or have been recently hospitalized, please describe :

Please list any health problems or recent health concerns (mark N/A if none): *

Please describe in detail medications you are taking:

Please list dates, course name and experiences with any meditation techniques or other self-development courses/techniques you have done

Agreement

It is compulsory to attend all sessions of the course. Taking notes and use of tape recorders is prohibited. Agreement: I understand that any benefits derived from this course depend upon the extent of my participation. I therefore accept full responsibility for the outcome and I willingly agree to follow all instructions and participate fully. I also agree that I will not disclose the content of this course to anyone. I further agree that I will not attempt to instruct others in any of the techniques used in the course until such time as I receive personal training from Project Welcome Home Troops or IAHV. By entering my name and date below I agree to the above.

Signature *

Today's Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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