Member Info Rooted Member Information Form Name First Last Email address Country of residenceAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsWhere did you hear about the Rooted Community?What called you to join the Rooted Community?What do you hope to receive through being part of the Rooted Community?Have you taken part in other forms of personal growth/spiritual processes? If so, please share what these were?Do you experience chronic fatigue, burnout or general depletion?Do you have a history of trauma that you’d like to share with Kerry? (this will help Kerry to ensure that you feel safe in this space).Is there any other information you believe Kerry should know to better support you in this group?Signing and submitting this form indicates that you agree to the following policies and values of the Rooted Community: I understand that my healing is my responsibility and no one can do it for me. I will get out what I put in. I understand that while Kerry is a psychologist this is not therapy and if I feel overly activated or traumatised for any reason I will both share this with Kerry and seek external support (Kerry may also recommend support). Out of respect to the women in this group I agree to keep all that is shared in this space confidential. I agree to not try to fix or advise other women in the group and I will only share from my own experience and not speak for others or assume I know what is best for them. I commit to immediately resolve any issues that prevent my monthly debit from going through. I agree not to share the program materials with women who are not in the Rooted Community. Some of the calls within the group will be recorded to be shared as teaching materials within the group and via email. As a participant, I may be recorded and I’m saying yes to this. If I do not wish to be recorded I will let Kerry know. I agree to my name and e-mail being kept in Kerry’s database to keep me up to date on group activity and future events. I acknowledge that I may unsubscribe from the group and from the database any time I wish. I will let Kerry know as soon as I wish to leave the Rooted community and my membership will remain active until the next debit order is due. I agree to all the above policies and commitments. SignaturePhoneThis field is for validation purposes and should be left unchanged.
