HOME
About Us
Our Story
Photo Gallery
Featured Media
Newsletter Subscription
Our Services
LIFESTYLE
>
Lifestyle Program
Lifestyle Application Form
Success Stories
Program Dates
Rates and Payment
Follow-Up Form
EDUCATION
>
Medical Missionary / Evangelism
Agricultural Program
Country Store
Farm
Resources
>
Faith Ventures
Eden Valley Cookbook
APPLY
Medical Missionary Evangelism Training Program Application
>
Student Reference Form
Agricultural Internship Application
Internship Application
Volunteer Application
>
Volunteer Opportunities
Reference Form
EV Interest Form
DONATE
CONTACT
EDEN VALLEY LIFESTYLE PROGRAM APPLICATION
Call
(970) 669-7730
to talk to a Lifestyle Department representative.
*
PLEASE COMPLETE
ALL REQUIRED FIELDS
*
Indicates required field
Suffix
*
Select one
Mr.
Miss
Mrs.
Ms.
First Name
*
Last Name
*
I wish to attend the program as a:
*
Select one
Lifestyle Participant
Lifestyle Support Person
Marital Status
*
Select one
Single
Married
Divorced
Widowed
Separated
If you are a Support Person, what is the name of the person you are coming to support?
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Occupation
*
Cell Phone Number
*
Home Phone Number
*
Email
*
Did your doctor refer you to the program?
*
Yes
No
If yes, please provide your physician's name and phone number.
*
I Wish To Attend Your:
14-Day Lifestyle Program
*
Select Program Date
January 5-19, 2025
January 26-February 9, 2025
February 16-March 2, 2025
March 9-23, 2025
March 30-April 13, 2025
April 20-May 4, 2025
May 11-25, 2025
June 1-15, 2025
June 22-July 6, 2025
July 13-27, 2025
August 3-17, 2025
August 24-September 7, 2025
September 14-24, 2025 (10-Day Program)
October 5-19, 2025
October 26-November 9, 2025
November 16-26, 2025 (10-Day Program)
November 30-December 14, 2025
14-Day Cancer Lifestyle Program
*
Select Program Date
January 5-19, 2025
January 26-February 9, 2025
February 16-March 2, 2025
March 9-23, 2025
March 30-April 13, 2025
April 20-May 4, 2025
May 11-25, 2025
June 1-15, 2025
June 22-July 6, 2025
July 13-27, 2025
August 3-17, 2025
August 24-September 7, 2025
September 14-24, 2025 (10-Day Program)
October 5-19, 2025
October 26-November 9, 2025
November 16-26, 2025 (10-Day Program)
November 30-December 14, 2025
Medical Information
Birth Date MM/DD/YY
*
MM/DD/YYYY
Height (foot/inch)
*
Choose One
*
Male
Female
Weight (lbs)
*
Age
*
What health concerns would you like to address?
*
Diabetes (Type 1)
Diabetes (Type 2)
Cancer
Hypertension
Overweight
Underweight
Arthritis
Stress Management
Heart Disease
Intestinal Disorders
Depression & Anxiety
Parkinson's Diesease
Lyme's Disease
Other
Select all that apply.
Please specify any details about your health concerns?
*
Allergies
*
Physical Abilities
Is English your first language?
*
Yes
No
Are you able to communicate fluently in English?
*
Yes, I do not need a translator.
No, I will need to bring a translator.
Not Sure
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you drink coffee, energy drinks, or caffeine?
*
Yes
No
Do you have medical insurance?
*
Yes
No
Are you able to dress, bathe and feed yourself?
*
Yes
No
Not Sure
Do you experience incontinence of any kind, even occasionally?
*
Yes
No
If yes, please explain.
*
Please list any past surgeries and injuries. If none please write "n/a"
*
Do you have any mobility or sight restrictions?
*
None
Use Cane
Use Walker
Use Wheelchair
Poor Vision
Hearing Loss
DO YOU HAVE A CENTRAL VENOUS CATHETER, OR PORT?
*
Yes
No
DO YOU TAKE INSULIN?
*
Yes
No
IF SO, WHAT METHOD DO YOU USE TO DELIVER INSULIN?
*
Have you ever been diagnosed with, or are you currently being treated for any psychological disorder?
*
Yes
No
If yes, please explain.
*
Are you currently taking medication for a psychological disorder?
*
Yes
No
If yes, please explain.
*
Describe how far you can walk without assistance?
*
I will be accompanied by a support person.
*
Select
Yes
No
I am the Support Person
If yes, please write the name of Support Person accompanying you
*
I understand that it may be required for me to bring a support person upon review of my application.
*
Yes
Note: All lectures, orientations, physician consultations, counseling, and health coaching will be delivered in English. If you do not speak or understand English well enough to communicate then you will need to bring a translator with you as a support person.
Please Specify Arrival Details
I will arrive via:
*
Airline
Car
Emergency Contact
Relationship
*
Select one
Spouse
Friend
Brother
Sister
Parent
Child
Other
Phone Number 1
*
Phone Number 2
*
Emergency Contact
*
How did you hear about Eden Valle
y?
How did you hear about us?
*
Friend/Word of Mouth
Internet Search
Internet Ad
TV Program
Radio
Barbara O'Neill
Other
*
Submit
HOME
About Us
Our Story
Photo Gallery
Featured Media
Newsletter Subscription
Our Services
LIFESTYLE
>
Lifestyle Program
Lifestyle Application Form
Success Stories
Program Dates
Rates and Payment
Follow-Up Form
EDUCATION
>
Medical Missionary / Evangelism
Agricultural Program
Country Store
Farm
Resources
>
Faith Ventures
Eden Valley Cookbook
APPLY
Medical Missionary Evangelism Training Program Application
>
Student Reference Form
Agricultural Internship Application
Internship Application
Volunteer Application
>
Volunteer Opportunities
Reference Form
EV Interest Form
DONATE
CONTACT
