Spring 2018 Escape Prep Assignment Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country 1. Why are you attending the Spring 2018 Escape?*2. Please set your intentions for The Escape: a. How do you want to feel at the close of our Escape time together?* 2b. What is 1 tangible you want to walk away with?*2c. What would you like to see shift 6-months after the Escape?*3. If you attended an Escape previously, what has changed for you since your last in-person time together? (record evidence from all areas: physically, mentally, emotionally, spiritually – nothing is too big or too small)*4. What do you expect to receive from this powerful community of like-minded individuals?*5. Where are you not at peace with food, your body and your energy?*6. Fill in the blank: “If I am completely at peace with food, my body and within my mind, I’m afraid ______________________________________________.” (please note: “nothing” is not an answer).*7. How you do one thing is how you do everything. So what patterns with food/body are repeating themselves in the areas of energy, time, money, and relationships with others? (please note: “nothing” is not an answer).*8. How would having peace with food, with your body and in your mind benefit you and your life?*9. Are you engaged in any kind of personal spiritual practice? *9a) If no, have you ever engaged in any kind of personal spiritual practice?10. How do you learn best? (please select your top 2) * a) I am a visual learner. It’s helpful for me to see things in images, diagrams and handouts. b) I a kinesthetic learner. I learn best by moving and doing. I like to use my body, hands or sense of touch. c) I am an auditory learner. It’s helpful to have things explained to me in a slow methodical way in a lecture type style. I also like to talk things out. d) I learn best with a tutor. I like private one-on-one support where we can go at my own pace and I can ask as many questions as needed. 11. Do you have any food, environmental or other allergies or sensitivities that we need to be aware of to ensure a peaceful supportive learning environment?*12. Is there anything else I need to know to be of highest service to you?*13. Complete the Escape From Emotional Eating Foundational Trainings (1-6) and be prepared to discuss these foundational tools in-person.* OK! I will do that! I'm still working on this so, I'd like to save for later. This iframe contains the logic required to handle Ajax powered Gravity Forms.