Online Lifestyle Application Form

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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*
SUFFIX*
FIRST NAME*
LAST NAME*
OCCUPATION*
MARITAL STATUS*
ADDRESS*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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*
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*
ARRIVAL*
DATE*
TRAVEL DETAILS*
Emergency Contact
Emergency Contact Name*
RELATIONSHIP*
PHONE NUMBER 1*
PHONE NUMBER 2*
Others

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About Us
Health Lifestyle Center
Our School
Store
Reach Us

Reach Us

3159 Cottonwood Creek Rd. Chewelah, WA 99109P.O. Box 332, Chewelah, WA 99109

life@thearkoutpost.orgCall Us: (833)284-3275

T.H.E. A.R.K. Lifestyle Application

Call to talk to a Lifestyle Department Representative for more information.

*PLEASE COMPLETE ALL REQUIRED FIELDS

Medical Information

Physical Abilities

Please Specify Arrival Details

Emergency Contact