Q’s Ministry of AIWP, “Meeting the One for Commitment”
10940 Wilshire Blvd., Suite 600                                                           Date:_________________________            
Los Angeles, CA 90024                                                                                         
(310) 443 4168                                                                                                                            Copy Right September, 2006
PRILIMINARY PERSONAL INFORMATION
The purpose of “Meeting the One for Commitment” at Q’s Ministry of AIWP is commensurate with the credo of the Association for Integration of the Whole Person (AIWP), which is love of life and people. Please complete the form, print and mail to Q’s Ministry of AIWP at the above address. If you like you may send along a photograph. $75.00 is the suggested donation, only if you like to help the non-profit. Your form can be inserted in a viewing binder along with others for confidential viewings at Westwood, Ca. on available Wednesdays. Only at the meeting and when you have a form yourself, you can choose two phone numbers of matching persons. On Wednesdays of available weeks you can return for additional names, numbers, for meeting your friends, colleagues, tea, coffee, talks and meditation. After having connected with someone you like and having seen him/her for a few sessions you can then return to be compared for your personalities, scientifically. The personality assessment tool we use is state of the art, recognized as “world class” and has advanced over the last 50 years. (Must be 21 years old or older to participate!)
Use check or print clearly.
Name (optional, use alias)______________________________________________________________
__Male __Female    Age_____    Birth Date _____________ Astro-Sign ____________                       
____Never Married ____ Engaged Before ____ Annulled ___Divorced ____ Divorcing  

Mailing Address (optional)________________________________________________________________

E-mail Address_________________________________________________________________________

 Phone (h)_________________(w)__________________ (c)______________________________                        

Age Group-s Seeking to Meet (Only check two please):(77+___)(70-76___) (63-69___) (56-62___)(49-55___)(42-48___)(35-41___)(28-34___)(21-27___)

Your Religion___________________ (Strength) ___Liberal ___Conservative ___orthodox            
Language(s) You Speak_________________________________________________________
Degree-s/Education______________________ Professional Title/s____________________
Hobbies_________ Sports____ Activities____ Group Engagements / Parties _______ Museum / Art_____                                  
Drinking Habits, if none state none___________ Smoking Habits__________________
Major Goals in Life_____________________Describe an Ideal Partner_____________________________
Your idea of Commitment / Fidelity _________________Your Idea of Trust_________________________
Your idea of Compassionate & Passionate Love_______________________________________________
Your Idea of Secure & Anxious Attachments__________________________________________________

Your Idea of Mutual Help & Reciprocity in Relationships_________________________________________
Your Idea of Empowerment___________________ Your Idea of “Chemistry” _______________________
How many Disagreements before Breaking-up ______Would you Seek Help for Your Relationships______
Your Idea of Cleaning / Organizing________________Your Idea about Wanting Children______________

Additional information you like to share___________________________________________________________________________
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Terms of Agreement
I agree to participate in this program and assume responsibility for its outcome. I agree to stop any contact with someone who does not wish to be contacted, agree not to subject each/all persons of the “Meeting the One for Commitment” program to disrespect, defamation, humiliation, denigration, demeaning, patronization, maliciousness, talking advantage of and/or by revealing his/her/ family /their private/health confidentialities. I agree to indemnify Q’s Ministry of AIWP and minister in each/all relation-s and/or connection-s to each/all of initial and/or ultimate outcomes that may arise from agreeing to participate in this program.
                                                               I accept, please initial_________.

Please Print Name: _______________________________________________________________________________ 

Please Sign Name: _________________________________________ Date: ________________________________