NORTHERN LIGHTS ALTERNATIVES, INC., OKC.
P. O. Box 12151, Oklahoma City, OK 73157
1-866-304-1481
Mastery Workshop
Information/Application Form
Some of the data used on this information/application form may be used for the purpose of filing grant
applications for Northern Lights Alternatives, Inc. Information on this form, as well as any information
discussed during the workshop, is considered strictly confidential.
Personal Information:
Name:________________________________________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Home Phone: ________________________Other Phone:________________________________
Birthday: ____________________________ Present age: ________________________________
E-Mail Address: _________________________________________________________________
Optional Information:
Where will you be staying during the workshop?__________________________________________
______________________________________________________________________________
Occupation: ____________________________________________________________________
Are you currently employed? ________________ Education: _______________________________
Other skills/abilities: ______________________________________________________________
Therapies and/or training in which you have participated in: _________________________________
_______________________________________________________________________________
What is your relation to AIDS/HIV: _____________________________________________________
_______________________________________________________________________________
How did you hear about the workshop: _________________________________________________
Anything else you would like us to know about you? ________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I have received clearance from my therapist and/or doctor(s) to take this workshop. (This is required
if you are receiving treatment)
____________________________________________________
Signature Date
The AIDS Mastery Workshop is being provided to you
free of charge. Please consider making a donation
so that we can continue our work. Recommended
donation: $25.00.
Mailing Address:
NORTHERN LIGHTS ALTERNATIVES, INC.
P. O. Box 12151, Oklahoma City, OK 73157
