* = Required Information

Dear Friend:

   The Voice in the Wilderness Mission would like to thank you for choosing our program to assist with your health needs. Our program has been designed to help in the health and healing of the whole person. Our goal is to teach you the causes of disease, its prevention, and its cures. Education is the key to good health and our Ten-Day Cleansing Program is designed to provide you with a broader awareness of what constitutes good health and how to maintain it.

   Our accommodations are home-like and simple, yet clean and comfortable. Don’t forget to leave the stress at home and come to relax and enjoy!

What to Bring

   The following items are things you will need to bring with you for your stay with us. Please bring warm comfortable clothing enough for ten days (Even during the summer months the morning temperatures tend to be cool in the mountains), water shoes, a bathing suit (for steam bathing), a warm or heavy robe, shower cap, warm night wear, any personal items, flashlight, pen and notebook, and any personal reading material or craft.

SORRY! NO PETS ALLOWED!

   Please fill out the information required on this registration form to enroll in a scheduled Ten-Day Cleansing Program. When this form is completed, please mail it to The Voice in the Wilderness Mission, 173 Bush Road, Savoy, Massachusetts, 01256. Or fax to: 508-635-9651.

Personal Information

Please Print Clearly!

Male Female
Married Single Divorced
Separated Widowed
Financial Information

DISCOVER MASTER CARD VISA AMERICAN EXPRESS

Please call to verify your program package price.

Arrival & Transportation Information

Car Bus Train Plane
Other
Pick-ups from the below listed locations are an extra fee.

$
$
$
Pittsfield Train or Bus Station
$

Call for updated pricing. Prices subject to change without prior notice. Prices are one-way and are to be paid directly to the driver. Prices do not reflect a tip.

To schedule a pick-up from Transport the People in Pittsfield, Massachusetts call the phone number below.

413-443-7111

Application Details

    Upon returning your application, it is important that you include a deposit (1/3 of total fee). We cannot guarantee any reservation without a deposit, and reservations are not confirmed without your deposit. Deposits are non-refundable, but may be applied to a rescheduled program within a four-month period. The remainder of your balance must be paid upon arrival. We do not provide payment plans. Sorry.

    If you have any questions or concerns please feel free to call us at this phone number during office hours, 9 am- 1 pm. 413-743-9743. The best time of the day to register is before noon.

GENERAL HEALTH INTAKE

Health Information

Yes No
Yes No
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Yes No
Yes No
Yes No
Yes No
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Yes No
0-1 2-3 More often
Yes No Sometimes
Yes No
Yes No Sometimes
Yes No
Yes No
Yes No Not sure
Medication & Nutritional Supplement List

Please include all doctor prescribed medications, plus any herbs or herbal supplements, vitamins, minerals, homeopathic remedies, etc. that you are currently taking.

Nutrition & Dietary Information

Meat eater Vegan Vegetarian (Zero animal products)
Lacto-ovo (Eggs and dairy) Raw food (No cooked food)
Semi Vegetarian (Fish and chicken)
1 Meal 2 Meals 3 Meals or more

At what times are these meals eaten?

: AM
: PM
: PM
I have no specific time schedule for meals
Yes No
Yes No
Yes No
Yes No Sometimes
Yes No Sometimes
Yes No
Yes No Sometimes
Yes No Sometimes
Yes No
Yes No Not nearly enough
Yes No
Yes No
Yes No
Yes No
Yes No Not sure
Yes No Occasionally I eat them
Yes No
Fruit juice Imitation-flavored drinks Soda Sports drinks Other
Please list all known food allergies

Physical Activity

Yes No Occasionally
1-3 times a week Everyday
Outdoors Indoors
Yes No
Yes No
Yes No
Yes No Sometimes
Yes No
Yes No
Water

Yes No
Yes No
Pale Dark
Yes No
Yes No Sometimes
Yes No
Yes No
Yes No
Yes No
Sunlight

Yes No
Yes No
Natural Artificial
Yes No
Yes No
Yes No
Temperance

Yes No
Yes No
Yes No
Yes No
Yes No Sometimes
Yes No Sometimes
Yes No
Yes No Sometimes
Air

Yes No
Yes No
Yes No
Yes No
Yes No
Rest


:
Yes No
Yes No
Yes No
Yes No Sometimes
Yes No
Full Part
Yes No
Yes No I don't know
Trust in God's Power

"And the peace of God, which passeth all understanding, shall keep your hearts and minds through Christ Jesus." - Philippians 4:7

"I can do all things through Christ which strengtheneth me." - Philippians 4:13

Yes No
Yes No Infrequently
Yes No
Social & Family Relationships

Yes No
Good Fair Very Poor
Yes No
Young Teens Adults
Yes No
Friends Alone
Yes No
Emotional Health

Yes No Infrequently Not sure
Yes No Not sure
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
CONSENT FORM FOR NATURAL THERAPIES

I,, whose current address is herby authorize The Voice In The Wilderness Mission, its hygienic practitioners, staff assistants, volunteers, and other attending personnel associated with or designated by them to admit me to their natural therapies program and treatment facility located at 173 Bush Road in Savoy, Massachusetts, and I herby record my consent for the same to perform upon me such diagnostic procedures and such natural therapeutic procedures involved in the (check appropriate box) 3 Day program, 5 Day program, 10 Day program as they, in exercise of professional judgment, decide are necessary for my continual treatment and care. It is my intention to consent not only to such procedures which have been anticipated, but to such further diagnostic and other natural therapeutic procedures which may become necessary or deemed advisable in the professional judgment of the Hygienic practitioner and other attending personal and as my treatment care continues.

The nature and purpose of the procedures, and expected discomforts, risks, complications, and benefits, if any have been fully explained to me. I am aware that the administration of natural therapies is not an exact science and results cannot always be anticipated. I also acknowledge that no guarantees or assurances have been made to me concerning the results from the procedures. I recognize that it is my responsibility to fully disclose to my attending hygienic practitioner any physical or emotional conditions and medications currently taking or recently taken which may be detrimental in any way to the success of the natural therapy procedures or to my ultimate recovery.

I also understand that any medications that I am currently taking, is my personal responsibility to continue to dispense, and take as prescribed by my medical doctor. And any discontinuance of this medication regiment is my personal decision and choice and I will assume all responsibility for any negative effects this may have upon my health.

I have been given the opportunity to ask questions and all of my questions have been answered fully and satisfactorily.

This consent is not only to the hygienic practitioners, staff assistants and other attending personnel of The Voice In The Wilderness Missions to whom I have entrusted my care, but to others associated with or designated by them. In granting this consent, I intend to assume the risk of possible unforeseen results and to be legally bound.

I agree not to revise, limit or alter this legal consent except in writing.

If patient is unable to sign or is a minor, complete the following: Patient is a minor, years of age or is unable to sign due to,


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