Spring 2018 Escape Prep Assignment Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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.