We will not distribute your information outside of the staff and key volunteers of Open Hearts Ministry. Contact information will only be used for registration purposes and to keep you informed and connected with the things going on at Open Hearts Ministry.
We are aware this is a very thorough and fairly long form. That is why we enabled the function to "save and continue later." If you reach a point and need to pause your process, you may click "save and continue" at the bottom of the form and receive a link that is good for 30 days to continue where you left off.Today's Date
Which Journey are you attending?*Please ChooseJourney Spring 2019Name
Nametag PreferenceIf you prefer to go by a nicknameMobile PhoneAlternate Phone (optional)Email*
Which contact method do you prefer?As technology progresses, we want to make our communications as effective as possible. We have found text gets the quickest response and want to offer text notifications. A text would be utilized to remind you regarding important deadlines in the process, to update you regarding outstanding balances, or ask a quick question about accommodation needs at The Journey. Texts will come from the # 269.389.9491.TextPhoneEmailAddress
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
OccupationCurrent AgeGenderMaleFemaleMarital StatusPlease ChooseSingleDivorcedMarriedIn RelationshipDo you have any childrenYesNoHow many children do you have?Have you attended a local Journey Group?YesNoHave you attended an OHM-led Journey before (either at Maranatha or a Regional Journey)?YesNoChurch AffiliationWould you like your own room?(Single Occupancy is an additional $200).
If you want a shared room, but don't have a preferred roommate, just select "no."
If you have a preference for roommate, please fill out "other" with their name.YesNoSmall Group Preference*In order to attend The Journey Continues co-ed group, you must have participated in an OHM-led The Journey Begins (either at a Regional Journey or at Maranatha).
NOTE: All female groups may have co-ed leadership even though all group participants are female. The Journey Begins co-ed groupThe Journey Begins all female groupThe Journey Continues co-ed groupEmergency Contact NameEmergency Contact RelationshipEmergency Contact Phone #Are you attending The Journey with a friend, family member, or church member?This helps to provide confidentiality for you in groups. We do our best to put people in groups apart from others they are attending with.YesNoWhat is their name?If you are coming with a group from a particular church or area, you may enter in the church name here.Please check any dietary restrictionsThis applies to The Journey at Maranatha only, where the Maranatha staff provides the appropriate food choices. At the Regional Journey participants are responsible for their meals.Gluten freePaleoVegetarianPeanut allergyDairy allergyDiabetic considerationsHave you been wounded/abused in any of the following ways?Domestic/Spousal?YesNoAge of Domestic/Spousal AbuseRelationship of Domestic/Spousal abuser to youEmotional?YesNoAge of Emotional AbuseRelationship of Emotional abuser to youPhysical?YesNoAge of Physical AbuseRelationship of Physical abuser to youSatanic Ritual?YesNoAge of Satanic Ritual AbuseRelationship of Satanic Ritual abuser to youSexual?YesNoAge of Sexual AbuseRelationship of Sexual abuser to youSpiritual?YesNoAge of Spiritual AbuseRelationship of Spiritual abuser to youVerbal?YesNoAge of Verbal AbuseRelationship of Verbal abuser to youWhen and where did you seek help?At what age did you seek help for your abuse, and to whom did you look for help?Dissociative Diagnosis?Are you aware of, or have you been diagnosed as being dissociative?YesNoHave you received professional or lay counseling?YesNoCurrent Care?Are you currently under the care of a professional counselor/doctor/or psychiatrist?YesNoIf you are currently under the care of a psychiatrist/therapist, we must have a recommendation from her/him for you to participate in the seminar. Once you have completed this registration form, you will be redirected to the home page of Your Journey Checklist. You may download the form there, have it signed, and upload it on the site, email to email@example.com, or text pic to 269.389.9491.
What are your personal expectations for this seminar?Are there life circumstances that could interfere with your Journey participation?The Journey can be very intense physically and emotionally. If there are any circumstances in your life (i.e. recent death of a loved one, medical condition, etc…) that could interfere with our ability to participate in The Journey, please write about your circumstances in the space provided.Waiver of Liability and Participation AgreementIn consideration of my electing to participate in this Open Hearts Ministry event, I agree for myself, my heirs and executors, successors and assigns hereby completely and unconditionally release and agree to defend, indemnify and hold harmless Open Hearts Ministry, Inc., its board members, officers, executive team members, leaders, presenters, employees and other representatives, from and against any and all claims, costs, causes of action, expenses, judgments, and liabilities of any kind whatsoever resulting from, arising out of or in any way relating to my participation in this Open Hearts Ministry event and any counseling or small group sessions in which I may be involved which use the methods or materials developed by Open Hearts Ministry, as well as my use of any information, methods or materials learned at or obtained through the ministry of Open Hearts Ministry.
Open Hearts Ministry reserves the right, should we believe that a participant’s behavior or actions are damaging or disruptive for the participant, other participants or in violation of event location policies, to remove such participant from the small group, the program and, should we feel it necessary, from the seminar location itself. Expenses incurred by this action will be the responsibility of the participant (hotel, taxi, airfare, etc…). In such case, participant fees are not refunded.I Agree to the Terms of Participation and Liability*
Registered Sex Offender InformationAre you on the registered sex offenders list? By answering yes or no and typing your name as an electronic signature, you are agreeing that you have answered this question truthfully.YesNoWhile answering yes will not preclude you from attending The Journey, this disclosure is required by law.Electronic SignatureMedia ReleaseOpen Hearts Ministry takes pictures and video footage during all of their events.Photos may be published and video may be aired for Open Hearts Ministry to use such items for ministry publications and purposes. I understand that if I indicate that I do NOT give permission for photos or videos of myself to be published, I must sit in the special seating section for those that do not wish to be photographed. Please check one.
I give my permissionI do NOT give my permissionCancellation PolicyCancellations made 60 days or more in advance of the event start date will receive a refund of all monies paid, less a $50 cancellation fee. Cancellations made 45-60 days in advance of the event start date will receive a refund of all monies paid, less the non-refundable $200 deposit. There are no refunds for cancellations made less than 45 days before the event start date.
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