Personal  Information	
Name:	                                                           Nickname:	Gender:	  Female            Male	
Address:		DOB:		
City/State/Zip:		Phone:		
Email:	                                                                                                    Alternate Phone:	
Religious Affiliation	
Church Name:		Denomination:		
Address:		Phone:		
City/ State/Zip:		Pastor’s Name:		
Emergency Contact	
Name:		Relationship:		
Address:		Phone:		
City/State/Zip:		Alternate  Phone:		
Where Employed	
			
Special Needs
This information will be kept confidential to the Hesed Board and retreat medical personnel.	

Check ALL conditions that apply to YOU:	Diet Restrictions
	 Diabetic
	 Gluten-Free
	
	Physical Limitations
	 Cane    Walker
                   	 Wheel Chair
	
	Visual  Impairment
	 Eye glasses
 Contacts	 Legally Blind	
	Speech Challenges	 Mild	 Moderate	 Serious	
	
Hearing Loss	 Hearing Aid		
	
Night Breathing 	 C-PAP Machine		
	Bed Preference

I am willing to sleep in a top
Bunk and can physically climb
Into and out of a top bunk.	 Top Bunk

 Yes

	 Bottom Bunk

 No

Personal hygiene needs:
Do you need help with bathroom, showering, or dressing?                                                  Yes                   No	

Do you need a 24/7 caregiver?                                                                                                   Yes                    No

Note: If you need a  24/7 caregiver, one must accompany you on the retreat.  Contact : LeAnn Wooten
                                                                                                                                                    (see below)	
List any specific types of Allergies (including food, medication, insect bites): 

Are you taking any medication with which you need assistance or reminders  to take?        Yes                    No

IF YOU ARE taking medication,  PLEASE complete the Hesed Medication Form. (This is mandatory information for your safety and well-being on the retreat.)
Also, please make a copy of your insurance card to attach to your Medication Form.
	
Permission	
Do we have permission to use photos/videos of you in publications for Hesed?                                    Yes                 No

If so, please sign:

Signature:                                                                                                        Date:	  

	

Guest Fee:     $50.00
	____ Enclosed is my fee
	____I request a partial scholarship (contact: LeAnn Wooten)

______________________________________________________________Date:___________________
Applicant’s  Signature

Mail your application form, your check (made out to HESED) along with your Medical form and a copy of your insurance card (s) to:

LeAnn Wooten
4683 Cedar Cliff Road 
Graham, NC  27253
( lw.ec.teach@gmail.com )