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Pathway Seminar Participant Form

Thank you once again for agreeing to participate in the Shared Crossing Pathway Seminar. We appreciate your interest, willingness, and courage to engage in this leading edge experience which endeavors to prepare participants for a conscious, connected and loving end-of-life experience.

Before commencing the Pathway Seminar, you need to complete and submit this form. It covers personal information, video consent and participation consent.

If you have any questions, don't hesitate to reach out to us at [email protected].

Many thanks,

The Shared Crossing Project Team

Click the button below to start.

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Question 1 of 21

What is your name and date of birth?

(mm/dd/yyyy) 

Question 2 of 21

What is your occupation? 

Question 3 of 21

What are your contact details? 

(your home address; phone, email address & emergency contact name and phone)

 

Question 4 of 21

Please tell us about your family members 

(include their name, relationship to you, age and whether they are living/deceased*)

If deceased, please give year of death & age at death

Question 5 of 21

With whom are you participating in the Pathway Seminar? 

Please provide the name and your relationship to him/her (e.g. spouse, parent, adult child, sibling, friend, other)

Question 6 of 21

What are your reasons for participating in the Pathway Seminar?  

 

(Select all that apply)
A

Deeper understanding of death and dying

B

Alleviate anxiety and/or fear of dying

C

Desire for a Shared Death Experience with someone you love

D

Other

Question 7 of 21

How did you learn about the Shared Crossing Pathway Seminar?

A

Counselor/Therapist

B

Participant in a previous course with Shared Crossing Project

C

Presentation by William Peters

D

Healthcare Facility (please provide name on next page)

E

Friend (please provide their name on next page)

F

Other (please describe on next page)

Question 8 of 21

If you answered 'healthcare facility', 'friend' or 'other' on the previous question, please provide more detail here 

Question 9 of 21

What is your goal or desired outcome for your participation in this seminar? 

 

Question 10 of 21

Have you or someone you know had a Near Death Experience or Shared Crossing Experience (ie. a Shared Death Experience or another extraordinary experience around death and dying)? 

(Yes/No). If yes, briefly explain

Question 11 of 21

Are you a caregiver of someone who is close to dying? 

A

Yes

B

No

Question 12 of 21

If you are a caregiver to someone who is close to dying, does that person know you are participating in this seminar?

A

Yes

B

No

C

Not applicable

Question 13 of 21

What are your opinions and feelings around the phenomenon known as the Shared Death Experience? 

Question 14 of 21

Are you currently in counseling, or have you been in the past? 

A

Currently in counseling

B

Have been in the past

C

No counseling now or in the past

Question 15 of 21

Are you currently taking any medications?

Yes/No (If yes, please list below)

Video Consent

We occasionally do filming of our events to be used exclusively for educational purposes. In the event that you would prefer your image not to be used, you can let us know on the following page and we will be sure to blur out your image.

Question 17 of 21

Shared Crossing Pathway Video Consent

 

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration.

 

I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

 

I also understand that:

* This material may be used in diverse educational settings within an unrestricted geographical area.

* This permission signifies that photographic or video recordings of me may be electronically displayed via the internet or in the public educational setting.

* I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. 

* There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

* This release applies to photographic, audio or video recordings collected as part of the Pathway Seminar only.

 

(Select all that apply)
A

I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

B

I would prefer my image not be used and request the Shared Crossing Project to blur it out in post-production.

Participant Consent

William Peters has developed practices and methods to facilitate the Shared Death Experience (SDE) so that others may experience its healing benefits. These methods are referred to as the Shared Crossing Protocols ('the Protocols'). 

As a participant in the Pathway Seminar, you will be engaging in the Shared Crossing Protocols. Implicit in your engagement is the understanding that the program is adapted and tailored to meet the specific needs (i.e. health requirements) and readiness of the participants. Therefore, the application and implementation of the Protocols varies depending upon the unique needs of each participant. 

Question 19 of 21

By selecting 'I agree' you are agreeing to work with Shared Crossing Project (SCP) staff and participate in the various components of the Shared Crossing Pathway Seminar that include the Shared Crossing Protocols. 

 

You acknowledge the following:

1) that the Protocols are an experimental exploration that applies knowledge, practices and methods to facilitate the SDE;

2) that the Protocols are currently being studied but have not been validated by commonly accepted research methods;

3) that William Peters, SCP , and the Family Therapy Institute or anyone affiliated with the Pathway Seminar do not guarantee that participants will experience an SDE;

4) that the Protocols are not a substitute for mental health services and does not claim therapeutic value for treating mental illness; and

5) that the use of the Protocols may cause uncomfortable feelings and/or cause emotional distress with family or loved ones.

A

I agree

B

I do not agree

Question 20 of 21

Intellectual Property 

 

The Protocols are the intellectual property of William Peters and Shared Crossing Project and cannot be used or shared without the expressed written consent of William Peters.

 

Furthermore, sharing information about the Protocols could lead to improper use resulting in uncertain outcomes. Thus, participants agree not to share any aspects of the Protocols with anyone other than their loved ones directly involved with SCP.

 

(Please refer others who may be interested in the Protocols directly to William Peters or SCP). 

A

I agree to the above statements and adhere to this requirement

B

I don't agree

Question 21 of 21

Confidentiality

 

As the relationship between SCP/Pathway Seminar staff and its participants is not the same as a therapist-client relationship, participants are not accorded the confidentiality granted by California State Law. Many aspects of the Protocols are conducted in groups with other participants making confidentiality difficult to maintain. If you wish to learn the Protocols in a confidential setting, contact William Peters or SCP directly and arrangements can be made to meet with you privately.

A

I have and read and understood the information about confidentiality

Confirm and Submit