Online application Name Age Address Email Phone (cellular/home/work) Preferred method of contact (phone, text, email) Program you are applying for Seven Levels of Quest: June 13-21, 2026 The Journey Home: July 15-19, 2026 Wilderness Quest: August 1-6, 2026 Traditional Vision Quest: August 1-8, 2026 Quest Protector Training: August 29-Sept. 7, 2026 Emergency contact (Name, phone, relationship) How did you hear about The Source Within? List and describe any medical conditions and history (surgeries, blood sugar levels, high blood pressure, asthma, history of digestive or kidney problems, etc.) List and describe use of prescription medications List and describe allergies (food, bee sting, etc) Are you under the care of a mental health worker? No Yes If yes, does he or she approve of your participation in this program? Yes No Do you have health insurance? Yes No If yes, please provide insurer, policy number, and phone contact. List and describe special diet requirements (ie, what foods can you *not* eat) How much sugar do you eat each day including processed sugar? Describe any training or experience you have related to The Source Within program Any other information we should know to serve you better? Your reasons and goals for attending (one full paragraph at a MINIMUM!) My signature indicates that I understand that The Source Within programs are conducted in outdoor environments where natural hazards exist. I accept these hazards as well as any possible accidents or injuries resulting from them. I waive and hold harmless The Source Within and its instructors from any liability caused by these hazards except where resulting from their negligence. Date Parent/Guardian (If applicant under 18) Date Submit
