Oneness Quest respects your privacy. Mailing addresses and email addresses shared with us are never shared with or sold to any other organization or person(s). They are for the exclusive use of Oneness Quest.

All information that you include in your medical and personal information forms is private and never shared outside of Oneness Quest, and is protected to the full extent of the law. The information requested is to provide us with a base of knowledge to help guide you to the most appropriate program for your needs, and to keep you safe and healthy within all of our programs.

    * All fields are required

    Subject

    Please Select a Program

    Name

    Gender

    Date of Birth

    Address

    City

    State

    Zip

    Country

    Home Phone

    Work Phone

    Your Email

    Cell Phone

    How did you hear about us?

      General Information

      Subject

      * All fields are required

      Name

      Date of Birth

      Your Email

      Gender

      Program Attending (required; if not listed here you don't need a medical form)

      Age

      Occupation

      MartialStatus

      Children

      In case of an emergency please contact:

      Name/Relationship

      HomePhone

      WorkPhone

      Address

      City

      State

      Country

      Zip

      Backup emergency Contact:

      HomePhone

      WorkPhone

      Address

      City

      Medical History

      Are you under the care of a medical professional for a current condition? If yes, please explain.

      If yes, have you discussed your participation in this program with him/her?

      (We are available to discuss with your doctor any medical needs you might have).
      Are you currently taking any medications? If so, please list medication and condition.

      If yes, what are the food requirements for your medication?

      Do you smoke?

      Have you had any major surgery? If so, please list the reason and the date. (text surgerydate* watermark "MM/DD/YYY")

      Please list all significant accidents and injuries and the approximate dates.

      Have you been hospitalized recently (past 2 years)? If so, please explain.

      List any allergies to medication:

      Do you have any SERIOUS food allergies that cause medical complications?
      If yes, please list them, and rate the severity on a scale of 1-10.

      **(Please note that we are not always able to accommodate mild food allergies/sensitivities.
      We are concerned with foods that you can NOT, under any circumstances, eat without serious side effects)

      Do you carry an EPI-PEN for your food (or other) allergy?

      List other serious allergies:

      List any areas of weakness in your body:

      On a scale of 1-10, how would you rate your current physical condition?

      Any history of the following-----------and/or-----------Any that are current

      Is there any medical condition not listed here that could impact your participation in this
      program that we should know about? Please describe.

      In the event of a medical emergency, do you have medical insurance?

      Please list insurance information (insurance company, contact information, policy #,name of insured and relationship to you, etc)

      Psycological Profile

      Are you currently under the care of a mental health professional? If yes, please explain.

      If yes, have you discussed your participation in this program with him/her?

      Have you ever experienced or been treated for depression? Please explain.

      Are you currently experiencing depression? If so, how severe?

      History of addictions:

      Do you now or have you ever suffered from any kind of anxiety disorder (i.e. panic attacks, night terrors, phobias, flashbacks, etc.)? If yes, please explain.

      Do you now or have you ever suffered from any type of dissociate disorder, or bipolar disorder (some types of energy work are contraindicated for these conditions)? If yes, please explain:

      Have you undergone any stressful events in the past two years that have impacted you significantly (i.e. loss of a loved one, divorce, loss of employment, etc.)? If yes Please explain:

      Have you ever been the victim of violence, physical or sexual? If yes, at what age?

      Do you have a current exercise routine/ physical practice? How often? How strenuous?

      How would you describe your current dietary habits
      (how much caffeine, sugar, meat, junk food, fruits and vegetables, etc. -- be honest!)

      Do you have any hobbies?

      Do you meditate?

      If yes, what type, since when, how frequently, and how long is each session?

      Have you ever done yoga?

      If yes, what type, and what is your level of experience?

      Have you ever fasted? If so, what type of fast and for how long?

      Have you ever done any type of pranayama / breathwork? What type?

      Have you studied any type of internal energy work (i.e. chi gung, tai chi, healing, etc.)?
      If so, what type and for how long?

      Have you ever done a Vision Quest? How many?

      Please list any other intensives, retreats, or Sacred Ceremony that you've been a part of:

      Are you and adherent of any spiritual or religious system? If so, which one?

      Are you happy with the direction of your life? Why or why not?

      How much control do you feel you've had over the direction your life is going? Please explain:

      Have you ever taken classes at the Tracker School or other programs at with Earth-Heart?
      If so, which ones?

      Have you had any significant training, spiritual or otherwise, that you would like us to know about?

      Participant Release of Liability

      I affirm that the confidential information, which I have provided, is accurate and complete. I understand that failure to disclose this information could affect my own safety and the safety of those around me, and I agree to hold. Earth-Heart harmless if full disclosure of a preexisting medical condition has not been provided. In the event of illness or injury, consent is hereby given to provide emergency medical care, hospitalization or other treatment, which may become necessary. I understand that parts of Earth-Heart programs may be physically or emotionally demanding. I agree to accept full responsibility and assume all risks, including those caused by acts of God, injury, death, and/or loss to my person and/or property knowingly and voluntarily, realizing that Earth-Heart will take all reasonable precautions to minimize these risks.

      I knowingly, voluntarily, and irrevocably waive any and all past, present, and/or future injuries, death, or loss,
      including those caused by acts of God, received while participating in activities conducted by Earth-Heart as a student, participant, spectator, and/or visitor, or in any other manner or form, taking part in the exercises, practices, excursions, and/or demonstrations. I certify that I am physically, mentally and emotionally capable to participate in the program I have applied for despite the rigors and dangers inherent in such undertaking. I acknowledge that the use of video recorders is prohibited.

      I understand that at no time during the Vision Quest program will anyone be allowed to stay in the base camp during the Quest other than the Quest protectors/staff - this includes Questers who decide to leave their Quest early. A ride will be provided by a staff member to an outside location were you can arrange hotel accomodations or an early flight home. This is to ensure the undisturbed energy in the protected Quest area for those who remain for the full 4-days and nights, and to ensure that the Quest protectors can focus 100% of their energy on those actively Questing. No refund is given for anyone who chooses to leave early.

      I understand that prices, policies and course dates are subject to change without notice, and that Earth-Heart is not responsible for any nonrefundable airfare at anytime. My signature below indicates my acceptance of these terms and my desire to participate in an Earth-Heart program. I also acknowledge that should I cancel, only $150 of the $300 nonrefundable deposit can be transferred (one time only) to another Earth-Heart program within 12 months of the original application. After 12 months, it is no longer transferable. If I do not notify Earth-Heart of my cancellation two weeks before the start of the class, none of the deposit is transferable.


      Photo / Media Release

      I release to Earth-Heart rights to use any photograph or video taken while participating in an Earth-Heart program to be used as deemed by Earth-Heart, including web site, brochure or other advertising.

      I hereby accept the Photo/Media Release

      Click on the link to download the PDF forms:
      Application Form
      Medical Form 

      Your application will not be considered complete unless we receive all of the following:
      Please mail this application (with a deposit, letter, medical form, and a recent photo) to
      The Oneness Quest
      P.O. Box 926,
      Fairfield, IA 52556

      Don’t forget to send the rest of your application materials in once you’ve paid your deposit.$300 non-refundable deposit if you have not already paid online. Payment is through PayPal (payments@earth-heart.net), or by personal check to Malcolm Ringwalt.

      The rest of the balance will be due at your arrival at the class via PayPal or a personal check unless other arrangements are made in advance.

      Please send the rest of your application materials once you’ve made your deposit. This is a $300 non-refundable deposit if you have not already paid online. All payments are made by personal check to Malcolm Ringwalt, Oneness Quest, or via PayPal. The balance will be due at your arrival at the class via PayPal or personal check unless other arrangements are made in advance

      If you cancel your reservation in a program you have applied for at least 2 weeks before the start of the class, of the $300 nonrefundable deposit, Oneness Quest allows $150 to be transferred (one time only) to any other program within 12 months of the original class application. If you do not notify Oneness Quest of your cancellation at least two weeks before the start of the class, none of the deposits is transferable.