Wellness House Adult Member Application Please complete this form in its entirety. The information below will be utilized for data purposes only. This information helps our organization to apply for grants to continue funding our operations. Name * First Last Preferred Pronouns * (Ex: "he, him"; "she, her"; "they, them") Date of Birth * Gender * Race / Ethnicity * Religious Preference * Marital Status * Military Status * — Select — Active Duty Veteran Military Dependent Nonveteran Address * City * State * ZIP Code * Email Address * Primary Phone Number * Preferred Phone Number for Contact Select Type of Phone * — Select — Cell Home Work Secondary Phone Number * If Preferred Phone Number Is Unavailable Select Type of Phone * — Select — Cell Home Work Emergency Contact Information Emergency Contact's Name * First Last Emergency Contact's Phone Number * Emergency Contact's Email Address * Relationship with Emergency Contact * Additional Information How did you hear about Wellness House of Annapolis? * Medical Information Name of Individual Diagnosed with Cancer (If you are the individual diagnosed with cancer, then disregard this question.) First Last Relationship with the Individual Diagnosed with Cancer (If you are the individual diagnosed with cancer, then disregard this question.) Name of Oncologist * Treatment Status (check all that apply) * Active Treatment Survivor Thriver Bereaved Type of Cancer * Stage of Cancer * — Select — I II III IV Date of Diagnosis * Program Waiver Agreement Please check each box to show that you acknowledge and understand the following statements. The programs at Wellness House of Annapolis which include but are not limited to Healing Touch, Massage, Reiki, Reflexology, Counseling, Support Groups, Mindfulness, Meditation, Educational and Nutrition Seminars, Exercise Programs, and Social Activities, are offered as complimentary services to those experiencing cancer either as a patient or a caregiver. I understand these services are not a substitute for medical treatment or the advice of my medical professional and that the teachers, practitioners, or participants do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I understand that social and special interest programs such as Book Club, Healing Music, Support Groups, Meditation and Mindfulness Classes, Therapeutic Art, and Member Gatherings are offered as a source of stress relief, peer companionship, support and relaxation and are not to be used as a substitute for medical treatment. I understand the leaders/guests do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I understand that Healing Touch and Reiki are simple, gentle, complimentary energy based approaches to health and healing that can assist my body in its natural ability to heal. I understand that the practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I understand that I should seek approval from my physician prior to receiving massage at Wellness House of Annapolis to ensure that my current medical conditions do not interfere with receiving massage. * I understand I understand the exercise programs which include but are not limited to Tai-Chi, Pilates and Yoga are offered by trained and/or licensed professionals to be beneficial to my health and well-being. I understand the class leaders do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. As with all exercise programs, I understand that I should seek the approval of my physician before beginning the practice. * I understand I understand that nutrition and other educational seminars are offered periodically by Wellness House in areas of interest to our membership. Presenters are invited by Wellness House because of their special knowledge or expertise, but under no circumstances do they diagnose conditions, prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. * I understand I affirm that I alone am responsible to decide whether to participate, and to what degree to participate, in the programs offered by WH. I hereby agree to irrevocably release and waive any claims that I have now or may hereafter have against WH and United Breast Cancer Foundation (UBCF) and its staff, practitioners, and volunteers. * I understand Limitations of confidentiality: If there is a threat to your life or others, this information cannot be kept confidential, and our counselors are mandated to report relevant information to the authorities. Limitations of our confidentiality include threats against yourself or another person, physical or sexual abuse or neglect. If you are experiencing a mental health emergency, support is always available, please call the Anne Arundel County Warm Line at 410-768-5522 or dial 9-1-1. * I understand Knowing the conditions described above, I agree, on behalf of me, my family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding my obtaining services at Wellness House of Annapolis. the maximum extent permitted by law, I release, hold harmless and agree to indemnify WH and UBCF and its officers, directors, staff, representatives, employees, and agents, from and against any present or future claim, loss, or liability for injury to person or property, which I may suffer, or for which I may be liable to any other person, related to my obtaining services from Wellness House of Annapolis, including but not limited to ordinary gross negligence. * I understand Signature Unless otherwise noted, programs are for ages 18 and older. Signature of Applicant * Date *
