First Name*:

Last Name*:

Street Address*:

City*:

State*: - Alabama Alaska Alberta Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Labrador Louisiana Maine Manitoba Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Foundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Yukon Territories

Zip*:

Email*:

Home Phone*:

Work Phone:

FAX:

URL:

Male:   Female:     Date of Birth:

In case of emergency, please notify:
Name:

Phone Numbers:
Home Phone:   Work:   Mobile:

Race:
African American Asian Caucasian Hispanic Native American
Other:

How did you hear about this program?
Flyer Ad Internet Other

Work: Full-time Part-time     Student: Full-time Part-time

Occupation or current professional title:

Organization or institution where you are currently practicing:

How many years have you been in this profession?

Degree/Discipline (e.g. MD, RN, MSW)

Have you ever served people who die or their families? Yes No
As a professional or volunteer?

Please rate your knowledge of end-of-life care?
Excellent Very Good Good Fair Poor

Personal Questionnaire
Please find a quiet moment and enough time to answer the following questions thoroughly

I. Professional Experience and Application of Training

1. Please describe the work you currently do, and include details of previous professional or volunteer work in health care or human service fields.
   
2. What is your motivation in serving others in your chosen field?
   
3. Why do you want to take this training?
   
4. Considering the course content and expectations, how would you propose to apply the benefits of this training to improve end-of-life care in your workplace or community?
   
5. What challenges do you anticipate in integrating this training with your work?
   

II. Contemplative Practice

1. What is your religious affiliation or spiritual tradition?
   
2. Please describe your present contemplative practice. (Meditation, prayer, reflection, other.) How often and how long do you practice?
   
3. Please describe any ways you have integrated your spiritual practice with your work.
   

III. Personal Experience and History

1. Is someone close to you presently facing serious illness or death?
   
2. Has someone close to you died in the last few years? Please describe briefly
   
3. Have you experienced the sudden death of a friend or family member? Please describe briefly.
   
4. Do you have a serious or chronic illness? Please describe briefly.
   
5. If you answered yes to questions 1-4, please describe what challenges you are facing as a result, on practical, emotional or spiritual levels.
   
6. Please describe briefly the most significant experience with death in your personal or professional life, and how this has affected your life.
   
7. For you, what are the most challenging and rewarding aspects of your work?
   
8. Have you ever had a near-death experience? Please describe briefly.
   
9. Based on your experience, what are your main unanswered questions about death?
   

IV: Personal Needs

1. Dietary restrictions (for meals during October residential component at Red Feather Conference Center - Shambhala Mountain Center):
   
2. Roommate Preference for October residential component at Red Feather Conference Center (circle one): male female
3. Please indicate and physical limitation you may have and how we can assist you:
   
4. Are you interested in CEU's? Please describe:
   
5. Additional Comments: