The Gate Personal Form - 2

Hi

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Please complete the required GATE Personal Form below. If you are new to Network Care, additional information may be required.

Name*
First Last
Best Phone*
In case we have a question about your form.
Email*
Gender*
- Male
- Female
Age*
Birthdate*
MM slash DD slash YYYY
Please answer the following questions:
Have you ever received Network Care?*
Are you currently receiving Network Care?*
How long have you received Network Care?*
What was the reason you began Network Care?*
If you are no longer receiving Network Care, please share why you stopped receiving care.
Have you ever received Chiropractic Care?*
Please share the reason you began Chiropractic Care*
Is there anything special about your spine or your Network/SRI care that you wish to share with The Gate staff?
Is there anything you would like The Gate Staff to know about your personal development, evolution or wellness?*
If you are currently taking any medication, please list the medications and reasons for taking the drug(s). If none, please enter "none."*
Have you ever broken your skull, vertebrae or any other bones? If yes, when? Please explain the details. If no, please enter "none."*
Have you had any surgeries? If yes, when? Please explain. If no, please enter, "none."*
Please describe any significant physical, emotional, mental or chemical trauma which you have experienced that you have not already shared.
Why do you wish to attend The Gate?*
How Did You Hear About The Gate?*
Who may we thank for referring you to The Gate?
Statement of Understanding

I understand that this is an Energetic Educational Seminar, from which I may experience a greater connection with my 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. I participate under my own volition and responsibility. I know that this weekend is part of an evolving process, and regular visits to my 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 practitioner permission to release my personal and clinical information to EpiEnergetics Institute for the purpose of assessing and caring for me 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 me 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 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 participate in The Gate and The Energetic Experience with the intent described above.
I affirm the information on this form is correct and accurate, and I Agree to participate in THE GATE with the intent described above*
- I agree
Electronic Signature*
I understand that by entering my full name below I am providing EpiEnergetics Institute with my electronic signature.
Today's Date*
MM slash DD slash YYYY

Hi

Please complete the required GATE Personal Form below. If you are new to Network Care, additional information may be required.

Please answer the following questions:

Statement of Understanding