Application Form

Please read the Terms & Conditions before filling out this form

Application Form

1: Personal Details

Name *

First

Last

DATE OF BIRTH *

GENDER *

OCCUPATION (Most Recent) *

CELL NUMBER *

Email *

ADDRESS & ZIPCODE *

2: Personal History

Thank you for sharing details of your medical history so that I can be prepared to give you necessary help and support.

How would you describe your illness/symptoms/issues/stuckness? *

When did your symptoms/issues begin? *

How has this affected your life? *

To help me assess your suitability for the seminar, please tell me if you have any medical or mental health issues that you have not yet mentioned on this form *

Do you know of someone who has used the Lightning Process to recover their health? *

HOW DID YOU HER ABOUT JODIE AND THE LIGHTNING PROCESS? *

How would you like to take the seminar? *

Accessibility

Please tick if you require wheelchair access at the course venue. *

Yes, I require wheelchair access.

Please tick if you would like to bring a support person with you. A support person is an individual who attends but does not complete the training course. There is no extra fee for your support person. *

Yes, I would like to bring a support person with me.

3: Application Questions

Do you feel you can influence your health? *

Do you believe you can get better/resolve your issues? *

HOW DO YOU HOPE TO FEEL WHEN YOU HAVE RESOLVED YOUR ISSUES? E.G. MORE ENERGIZED, MORE FOCUSED ETC. (PLEASE LIST AT LEAST 4 THINGS) *

When you resolve your issues, what would you love to do with your life? (PLEASE LIST AT LEAST 4 THINGS) *

4: Confidentionality

Do you agree to maintain confidentiality with information shared by others during the training *

Yes, I agree.

5: Terms & Conditions

If you are under 18 your parent or guardian will need to read and accept the Terms and Conditions on your behalf.

Agreement *

I have read and accepted the Terms and Conditions

name (of participant, parent or guardian), signature and date *

As a parent or guardian, what is your relation to the client? *

I would like to have my attendance certificate logged with the Lightning Process Head Office *

I wish to receive occasional and relevant correspondence about developments in the Lightning Process *

I give my permission to be contacted at regular intervals to monitor my progress for the purpose of further research into the Lightning Process *

6: Emergency Contact

So that we can contact someone closet to you in the case of an emergency please provide:

Emergency Contact Name *

Emergency Contact Cell Number *

Submit

Apply