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Full Name *

First Name

Last Name

Are you over 18 years old? *

Yes

No

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

Country

(###)

###

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Alternate Phone

Country

(###)

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Were you referred by one of our previous LIVE-IN guests? *

Yes

No

How are you planning on traveling here? *

Bus

Car

Plane

Train

Do you have any physical limitations? *

Difficulty climbing stairs, walking long distances, exercising, etc.

Yes

No

Do you have any visual limitations? *

Difficulty reading handouts, a whiteboard, making out images in a monitor screen, etc.

Yes

No

Do you have any hearing impairments? *

Yes

No

Do you have any sleeping or snoring problems? *

Yes

No

Do you have any food or general allergies? *

Yes

No

To your knowledge, have you been directly in contact with anyone that has been tested positive for COVID-19? *

If the answer to this question becomes yes 1-2 weeks before the program starts, please notify us so your reservation can be transferred to another date.

Yes

No

To your knowledge, have you been exposed to anyone who has been in contact with someone that has tested positive for COVID-19? *

If the answer to this question becomes yes 1-2 weeks before the program starts, please notify us so your reservation can be transferred to another date.

Yes

No

Have you had any of the following symptoms within the last week? *

Fever or Chills

Shortness of Breath or Difficulty Breathing

Congestion or Runny Nose

Sore Throat

Coughing

Fatigued Muscles or Body Aches

Headaches

New Loss of Taste or Smell

Nausea or Vomiting

Diarrhea

None

Do you currently have COVID-19? *

If the answer to this question becomes yes 1-2 weeks before the program starts, please notify us so your reservation can be transferred to another date.

Yes

No