Into the Dark Womb – An Animas Quest for Women

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* These fields are required

1 Welcome

2 Tell Us About You

Phone *
Gender *	This information is used to help the guides understand the demographics of this program.
Birth Date *
Age at beginning of program *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Vocation *

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3 Health Information

Height *	(ft, in)
Weight *	(lbs)
Special Diet *
Diet Notes *
Please list any current medical conditions *
Are you currently (or within the past two years) receiving treatment from any health care professional(s) for any physical condition? *
If yes, please list and explain. If you are under the care of any health care provider(s), do they approve of you engaging in this activity? *
Are you currently taking any medication(s) or supplement(s)? *
If yes, please list the medications and supplements and their purpose. *
Are you currently (or within the past two years) receiving treatment from any health care professional(s) for any psychological reason? *
If yes, please list your current psychological conditions for which you receive treatment. Does your provider approve of you engaging in this activity? *
Are you currently taking any psychiatric medications? *
If yes, please list the medication(s) and their purpose. *
Do you plan to alter any medication routines prior to or during any portion of this program? *
Have you ever had an eating disorder (anorexia/bulimia nervosa, binge eating, etc)? *
If yes, please list dates, type of disorder and where you are with it now. *
Have you ever had an addiction? *
If yes, please describe the condition, any treatment, and dates of treatment. When was the last time you participated in addictive behaviors? *
Have you ever been diagnosed with heart disease? *
Have you ever had a heart attack? *
If yes, please list date and explanation. *
Do you have a heart murmur or pacemaker? *
Have you ever been diagnosed with high blood pressure? *
Please list your usual blood pressure. *
Please list your resting pulse rate if you know it. *
Have you ever experienced a seizure of any kind? *
If yes, please explain *
Have you ever had a lung disease (asthma, emphysema, etc)? *
Do you use a CPAP machine, supplemental oxygen or have difficulty breathing at high elevations? *
Are you hypoglycemic or diabetic? *
Do you have hemophilia? *
Do you wear a medic alert bracelet? *
If yes, please list what it is for *
Please list the date of your most recent tetanus shot *
Do you have any allergic reactions to any environmental substances, food or drugs? *
If yes, please list the substances and describe the severity and type of the reaction. *
Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock? *
If yes, please explain *
How would you rate your present degree of physical fitness? *
Do you have any disabilities of the back, knees, hips or ankles? *
If yes, please explain *
If you walked on level ground for a mile at an average pace, would you get out of breath, have chest pain, leg pain, or develop muscle fatigue? *
If yes, please explain *
Are you pregnant? *
Approximately how many nights have you slept outside (in a tent, tarp, or otherwise)? *
When was the last time you camped outside (vs RV camping)? *
Can you set up your own tent and/or tarp? *
Can you carry a 30-pound backpack for 1 -2 miles? *
Can you carry a 50-pound backpack for 1 mile? For 3 miles? For 5 miles? *
Have you ever spent time solo in the wilderness? *
If yes, for how many days? *
Do you intend to fast on the solo portion of the program? *
Have you fasted before? *
If yes, for how long? What was that like for you? *
Have you reviewed your medical conditions, your medication and fasting with your physician? Please describe *
If yes, please list and explain *
What else do you feel we should be aware of or that you are concerned about regarding your physical ability and condition? *
Is there anything else you feel we should be aware of or that you are concerned about regarding your emotional condition and history to help us be of better service to you? Please share even if you feel it isn’t likely to be relevant. *
Emergency Contact #1 Info *	Please list your emergency contacts' name, relationship to you & cell phone number.
Emergency Contact #2 Info *	Please list your emergency contacts' name, relationship to you & cell phone number.
Do you have health insurance? *	•Please note that in the United States it is essential to have your own health insurance. If you are an American, please ensure that you do so. An emergency room visit can cost up to $4,000 while an overnight hospitalization may cost close to $10,000 USD. •If you are a visitor from another country, please consider obtaining travel insurance from your own country to cover any expenses related to the exorbitant US health care system costs.
If yes, please provide information below *	Please list health insurance company name, company phone number & policy number
Mental Health Provider Name and Phone Number *	This information will only be used in the event of an emergency.
Medical Provider Name and Phone Number *	This information will only be used in the event of an emergency.

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4 Application Questions

Please list any Animas immersions you’ve attended with the program name, year, and guide/s. *
Which books by Bill Plotkin have you read? *
Please list Animas guides with whom you have participated in one-on-one mentoring, and dates of the mentorship. *
Briefly, list the most relevant non-Animas soul-oriented or nature-based human development work you’ve experienced and how it’s shaped you. (This may be wilderness and nature connection immersions, ecotherapy, depth psychology, vision fasts, indigenous offerings, other spiritual disciplines, or plant medicines.) *
Why is now the time to engage in this particular Animas offering? *
What mysteries are you in conscious relationship with, including (but not limited to), your experiences with images, symbols, myths, motifs, truths, deep allurements, dreams, particular living presences of Earth, ancestors, your own body, etc.? Please be concise. *
This Animas immersion/ceremony brings us near our emotional, spiritual, and psychological edges as a natural part of the unwinding of our personal identity and cultural conditioning. Challenging terrain! What do you know about your inner protector strategies that might arise during challenging psychospiritual opportunities? What inner resources do you have on board to navigate ego-transformative experiences? *