Thank you for taking the time to fill out the Application Form below. The information you have provided is kept completely confidential and aids us in ensuring that when your application is approved your Vision Quest will be a safe and rewarding experience.

Contact Details
Name *
Name
Address
Address
Application Details
Date of Birth *
Date of Birth
Have you ever fasted before? *
Medical History
Overall how would you rate your current physical fitness and health? *
Are you under the care of a medical professional for a current condition? *
If yes, have you discussed your participation in this program with him/her?
Are you currently taking any medications? *
Are you currently under the care of, or have ever seen a mental health professional? *
Do you have or have you ever had any blood sugar problems? *
Overall how would you rate your current mental health and general attitude to life? *