Home
About Us
Health Lifestyle Center
Our School
Store
Reach Us
Donate
T.H.E. A.R.K. Lifestyle Application
Call to talk to a Lifestyle Department Representative for more information.
*PLEASE COMPLETE ALL REQUIRED FIELDS
I WISH TO ATTEND THE PROGRAM AS A
*
Lifestyle Participant
Lifestyle Support Person
Applying for T.H.E. A.R.K at sea Home Health Program
SUFFIX
*
Mr.
Miss
Mrs.
FIRST NAME
*
LAST NAME
*
OCCUPATION
*
MARITAL STATUS
*
Single
Married
Divorced
Widowed
Separated
ADDRESS
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
CELL PHONE NUMBER
*
HOME PHONE NUMBER
*
EMAIL
*
I WISH TO ATTEND YOUR
*
4-Day Weekend Restoration Session
10-Day Detox Health Retreat
1-Week Cleanse My Temple Session
2-Week Made the Whole Session
3-Week Touch of Faith Session
I am applying for T.H.E. A.R.K. at sea Home Health Program
4-DAY WEEKEND RESTORATION SESSION
*
10-Day Detox Health Retreat
*
April 4-13 2023
1-WEEK CLEANSE MY TEMPLE SESSION
*
2-WEEK MADE WHOLE SESSION
*
3-WEEK TOUCH OF FAITH SESSION
*
Medical Information
BIRTH DATE
*
Date Format: MM slash DD slash YYYY
GENDER
Male
Female
HEIGHT (FOOT/INCH)
*
WEIGHT (LBS)
*
AGE
*
ALLERGIES
*
PLEASE SPECIFY ANY DETAILS ABOUT YOUR HEALTH CONCERNS?
*
WHAT HEALTH CONCERNS WOULD YOU LIKE TO ADDRESS?
*
Diabetes (Type 1)
Diabetes (Type 2)
Cancer
Hypertension
Overweight
Underweight
Arthritis
Thyroid Issues
Hormonal Issues
Stress Management
Heart Disease
Intestinal Disorders
Depression & Anxiety
Parkinson’s Disease
Lyme’s Disease
Other
Physical Abilities
ARE YOU ABLE TO COMMUNICATE FLUENTLY IN ENGLISH?
*
Yes
No
DO YOU SMOKE?
*
Yes
No
DO YOU DRINK ALCOHOL?
*
Yes
No
DO YOU DRINK COFFEE OR ENERGY DRINKS?
*
Yes
No
DO YOU HAVE MEDICAL INSURANCE?
*
Yes
No
ARE YOU ABLE TO DRESS, BATHE AND FEED YOURSELF?
*
Yes
No
DO YOU HAVE ANY MOBILITY OR SIGHT RESTRICTIONS?
*
None
Use Cane
Use Walker
Use Wheelchair
Poor Vision
Hearing Loss
ARE YOU ABLE TO WALK TWO CITY BLOCKS WITHOUT ASSISTANCE?
*
Yes
No
Not Sure
FOR ACTIONS ABOVE THAT I AM UNABLE TO ACCOMPLISH ON MY OWN, I WILL BE ACCOMPANIED BY A SUPPORT PERSON SHOULD I BE ACCEPTED INTO THE PROGRAM
*
Yes
No
Not Applicable
DO YOU EXPERIENCE INCONTINENCE OF ANY KIND, EVEN OCCASIONALLY?
*
Yes
No
IF YES, PLEASE EXPLAIN.
*
HAVE YOU EVER BEEN DIAGNOSED WITH, OR ARE YOU CURRENTLY BEING TREATED FOR ANY PSYCHOLOGICAL DISORDER?
*
Yes
No
IF YES, PLEASE EXPLAIN.
*
ARE YOU CURRENTLY TAKING MEDICATION FOR A PSYCHOLOGICAL DISORDER?
*
Yes
No
IF YES, PLEASE EXPLAIN
Please Specify Arrival Details
I WILL ARRIVE VIA
*
Airline
Car
Bus
Not applicable
ARRIVAL
*
January
February
March
April
May
June
July
August
September
October
November
December
DATE
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TRAVEL DETAILS
*
Emergency Contact
Emergency Contact Name
*
RELATIONSHIP
*
Select one
Spouse
Friend
Brother
Sister
Parent
Other
PHONE NUMBER 1
*
PHONE NUMBER 2
*
Others
This iframe contains the logic required to handle Ajax powered Gravity Forms.