Child Gate - Personal Form Enhanced

Parent Attendee (Your) Full Name*
Parent's (Your) Email*
Parent's Best Contact Phone #*
In case we have a question about your form.
Child's Name*
Child's First Name Child's Last Name
Your Child's Identifier in Our System - Do NOT Make Any Changes to this Field*
Gender*
- Male
- Female
Gender of your child
Your Child's Age (on the date of the event)*
Your Child's Birthdate*
MM slash DD slash YYYY
Gate Location*
Date of Event*
MM slash DD slash YYYY
Part I. About Your Child
Why do you want your child to attend this Gate?*
Is your child currently taking any medication? If yes, please list below and include the reason for taking the drug(s).*
Has your child ever broken his/her skull, vertebrae or any other bones? If yes, please provide when and details.*
Has your child had any surgeries? If yes, please indicate when, why and outcome.*
Is there anything special about your child's current life, health and/or function that you wish to share with Donny Epstein and the Gate staff?*
Is there anything you would like the Gate Staff to know about your child's personal development, evolution or wellness?*
What does a vital and fulfilled life look like to your child?*
What does your child need to be more sustainable in his/her life right now?*
What energy enriching or constructive factors are currently working for your child in his/her life?*
What destructive or energy consuming factors are currently working against your child in his/her life?*
Describe your child's awareness of energy in your body or around you.*
Part II. Concerns or symptoms, and how they may influence your child's life
Does your child have a current or recurring health/life situation or concern?*
- Yes
- No
When did this situation or concern begin?*
Have you done anything about this situation or concern, or been given advise or treatment for it?*
- Yes
- No
What were you told?*
What was done?*
Did it seem to work?*
What was different about your child after treatment?*
What was different about your child's condition or symptom after treatment?*
Have your child's concerns changed since treatment?*
Please select the level to which this health concern(s) affects these aspects of your child's functioning/quality of life*
Have any other family members had the same or similar concerns?
- Yes
- No
Who was it, and what did he/she do about them?
How aware of this is your child during the day?
- 1 - Not Aware
- 2
- 3
- 4 - Extremely Aware
How aware of this is your child at night?
- 1 - Not Aware
- 2
- 3
- 4 - Extremely Aware
Is there any time of day which makes your child more/less aware of the above?
Is there an activity during which your child totally, or almost totally, forget about the condition, symptom or concern?
Why do you think this has happened, or continues to happen to your child?
Do you think this is the sole cause?
- Yes
- No
What else is involved?
If this condition or symptom were to go away tomorrow, what would be different about your child's life?
Is your child doing anything differently because of this condition/symptom/concern?
Since the development of this condition/symptom/concern:
- Has your child changed any habits?
- Held or touched his/her body more often or differently?
- Moaned, cried, or made sounds that he/she usually does not make
Check all that apply
Which best describes your child's current feeling about himself/herself and his/her situation?

Statement of Intent
I understand that this is an Energetic Educational Seminar, from which my child, a minor participant may experience a greater connection with his/her self organizing wisdom. Varied models of consciousness and models of spirituality will be presented and may be integrated into this program. I understand that this seminar is not a means of diagnosing or treating any condition, physically, emotionally, mentally, psychologically, or spiritually. My child participates under my own volition and responsibility. I know that this weekend is part of an evolving process, and regular visits to my child's network practitioner and other frequented healing facilitators are suggested following the program. Although all of the entrainers are Doctors of Chiropractic, they are offering care for energetic awareness and as an educational tool at this transformational program, and not acting in their capacity as health care practitioners. Various classes may include movement, breathing, yoga, toning, meditation, and other forms of internal reeducation and awakening are offered during The Gate. Any of these types of programs in and of themselves may awaken physical and emotional feelings or memories. It is understood that sometimes healing during the transformational process feels wonderful, or ecstatic, and sometimes it does not feel comfortable at all. It is further understood that if any attendee is currently in the care of a psychologist or therapist, that consent has been given by the practitioner to attend this weekend. I grant my child’s practitioner permission to release my child’s personal and clinical information to EpiEnergetics Institute for the purpose of assessing and caring for my child in relationship to this program. I understand that portions of the program may be recorded through photo, video and/or audio and I agree to allow EpiEnergetics Institute and its agents to use photos/video/audio taken of my child for for educational, commercial, marketing, and public relations purposes. Any and all of said reproductions are the exclusive property of EpiEnergetics Institute and EpiEnergetics Institute is the exclusive copyright owner in perpetuity. I shall have no claim, right or interest to any of these reproductions and my signature hereto grants permission to EpiEnergetics Institute to use any of said reproductions in any responsible manner, including, but not limited to: publications, advertisements, web sites, and/or commercial products. I understand and agree to share my child’s personal information and findings with Donny Epstein’s research and development team to further research and advance the technologies Donald Epstein has created so far and which are part of this program. The information will be exclusively used for research and development purposes. I understand the information on this form and agree to have my child participate in The Gate and The Energetic Experience with the intent described above.
Electronic Signature*
I, the undersigned parent or legal guardian, agree to the above Statement of Intent on behalf of my child with my electronic signature*
Today's Date*
MM slash DD slash YYYY

Step 4: Complete and submit the Enhanced Personal Form below for your child:

Step 1 of 7

Part I. About Your Child

Part II. Concerns or symptoms, and how they may influence your child's life

Please grade the level to which this health concern(s) affects these aspects of your child's functioning/ quality of life

Part llI: Overall Wellbeing

Part IV: Stress History - Physical

During the day my child does the following:

Medical Treatment

Part V: Stress History - Mental/Emotional & Chemical

With each of the following potential stress situations, please check all that apply:

Part V: Additional Information

Which of the following describes your child's current state? What are the top 3? (number in order 1-2-3)

Statement of Intent