Dear Friend:

BEACON OF HOPE REJUVENATION LIFESTYLE CENTER

3534 Route 82 Millbrook, NY 12545

(917) 658-4886 (845) 677-3093 (845) 344-7434

We here at Beacon of Hope Rejuvenation Lifestyle Center would like to thank you for choosing our Program and realizing the need to take control of your health. Our program is designed to help you better yourself as a whole person. It is our desire to teach you the cause of disease, its prevention, and its cure. Education is the key to good health, and our Cleansing Program is designed to provide you with a broader awareness of what constitutes good health. So, sit back and enjoy learning about your health !

What you need to bring is warm, comfortable, loose clothing for your stay and other items listed on the enclosed checklist.

Upon returning this Application, Questionnaire and Disclaimer, it is important that you include a deposit of 1/3 of the total fee. We cannot guarantee any reservation without a deposit. Deposits are not refundable but can be rescheduled within a two month period. The remainder of your balance must be paid upon arrival. Please make checks payable to Jerry Jamel. There is a $28 charge for "returned" checks.

If you have any questions or concerns, please feel free to call us at any of the numbers listed above, and if we are not in, we will certainly return your call.

APPLICATION Please print clearly

Home Tel. No.: ------------- Cellphone: ___________ _

Arri v a 1 Date: -------------- Approx. time of arrival: ------How Arriving: car bus train _ _.plane other: -------

Any pick ups/drop offs are an extra fee and is to be paid to the driver at the time of transport. Fees

are roundtrip:, Airports: Stewart : $90. LaGuardia: $145. Kennedy: $150. Albany: $137.

White Plains: $1 15. Plus tolls.

Call ahead for other pick up areas. *Metro North Train Stations: $25 .00 Hudson Line: Take Metro

North to last stop - Poughkeepsie. OR - Harlem Line: To Dover Plains or Tenmile River Greyhound Bus: Call 1-800-23 1-2222 or on line to www.greyhound.com. Destination : Poughkeepsie, NY

Amount of Deposit Enclosed: $ ____ _ Check# MO# --- ---------

Make checks payable to Jerry Jamel.

If you anticipate any changes or cancellation with your reservation, please notify us two weeks in

advance. "No-shows" are non-refundable. Thank you for your consideration.

Return this sheet with your deposit

Beacon of Hope Welcome letter.pp! rev. 1216/2014

Welcome / Bienvenido "The doctor of the future will give no medicine but will interest his patients in the care of the human body, in diet. and in cause and prevention of disease"

"El medico del futuro no dara medicamentos, pero sera de interes sus pacientes e n el cuidado del cuerpo humano, en la dieta, yen la causa y a la prevenci6n de la enfermedad"

CLIENT QUESTIONNAIRE [~ Today's Date: __________________ _

Client Information / 1nformacl6n del Cliente

Name: ___________________ _ Home Telephone: ___________ _ (Nombre) (telefono)

Address: ______________________________________ _ (Street address, apt. II I direccian - ca/le y apartamenta)

(city, state, zip code I cuidad I est ado, zona postal)

Sex I sexo : Male I Hombre _ J Female I Mujer Birthdate I fecha de nacimiento: __________ _

Height I altura:. ________ _ Weight I peso: _________ _ Age/ edad: _________ _

Cellphone: _________________ _ Email: ___________________ _

St atus: Estado civil:

Married Casada

Single Soltera

Widowed Viuda

Divorced Divorciado

Separated Separados

Other _________ _

Otro --------

Symptoms - Reasons for Your Visit I Sintomas - Razones de su vislta

Reasons for your visit I Razones por su visita: ___________________________ _

When did you first notice the symptoms/ lCuando not6 por prlmera vez los sintomas?: _______ ____ _

Is the Condition getting progressively worse I l Es la condici6n cada vez peor? __ yes/ si __ no

Where specifically is the problems(s) located I l Donde es especfficamente los problemas(s) ubicado / loca lizado?:

Refer to the following page for various health issues. Please check what may apply to you either currently or in the past.

Vaya a la paglna siguiente para diversos problemas de sa lud. Por favor, indique lo que se apllca a usted en la actualidad o en el pasado.

Page 1 of 4 I PAglna 1 de 4

!J EA L!JJJ!S'.rn.R\'. Chc<.:k only thll&C conditions thut you cu1Tcn1ly have or had in !he past (pAgc ! E11glish}

~~ ~ ~ • <?.'b q_'-q;Oi Problem Problem Problem

Problem

Abs(1nt·min<led Heartburn I GERD Hcmt Pounds HHnl 'l'uberculosir;

Aciw lndig0fition Hemorrhoids Ve11crClt1l lnfcct.iom;

Aid8 I HIV lnflnmmatory

Hernia Wake Up 'l'ii·cd __llim:cl_!);""' W1l12L

Alcoholimn Luct,01,m lnt.oleruncc High Blood Pt·ei<Stu•c Weir,hl problem

Allorgice Lower Bowel Gas I

H(Jt. Moi:it. of Urn time J:'bt.nlnnce

A\11,lwimer's Digense Ulcers lnfel'tilit.y problemfl

A1wmia R11domctrit1sis lnsomi;ia

Appendicitis Di11,~.incm1 frritab!e befol'c u menl

Al'lhdiis c>1' RA Eat when Depressed Itching ofthe

Ann,/ll< ''""' Ast.hma gat. when Nei·vous lt<.:hing of the Nairn

Aul.ism Eat !.o Hcliof Fat.iguu Kidnoy Stones

Bad{11chm~ Ec~t!ma Lighl·hendndnnss

]fad Brcat:h EmphyBerna Low Blood Pl'osaui•e

Ble<idii\g (whol'o) gxccifisivc l"oni· Lt1mbago

C11nctit (typo) Excru-isivn H11nger Menstnw.tion, heavy

Chei-;t Paini:- Exce1;sivo Wol'l'y Mcirntrtu<tion, skip

ChilJg /Cold Skin Eye Pl'oblcms l'vl<?:ntal Disorder

Cho]cr;tcrol, hiRh Cnt.ai-aels Motion SidtnCJsB

Cold Hunds/Fcct. Glaucom11 Nauaen

Conslipntiou Blindnc1rn Ncl'V()l!B DlBol'dr!'r

Cravings Faint wlwtt hun1p·y Night BlindnesR

Cyi;ts Fatigue (tired) Obesity

Deprm;slon Feel shi~ky if hungry Painful buw0)

ont

Diabl\tcs FibroidR I J<'ibror>ik Pant.:rea.titi1>

Diarrhea Foul smelHni.bowO!··

PnrkinHon'll DiHcm:ie lmilll!!n!W.L

Difficulty lfrcathing !~n!quent Co!dR PoliomyclitiR

Dif."((l!:!t.iW! Di1>m·de1·1> Frequent Kidne.v

P1'0iitatc tl'oublu '""'

Coliti1:1 FrGquenl u1·in11lion Ht!spit•atot·y pt•oblmns

Ct'oh11's Diacac Gnllstom~a Hhoumutic P(Nci·

Digustion t.oo fuat Hay Fever Sexunl issues

Divurticulitis I (lf>ifi Head11che1S I migi·ainoB Sinusitis

Gulh:tonllfl lJC'art Di8easo Skin Prob!nnrn

G11stritii> Angin1J. Sluggish foelini;;

Ulut..en lnto!eni.nce Athr1rorwlo1·0Bifl Sti•oaH ll>H wL

H. Pylol'i Cormrnry Artery

Swollon Oland:; });,.,, ' Your name· Health history revised 7 1114

Taking medications? / lEsta tomando medicamentos? no _ yes/ si If yes, the name, dosage and frequency / Si la respuesta es sf, el nombre, dosls v frecuencia

Name of Drug/ Nombr• del "rmaco

""'f:orWh~Pr:bi~~(~)f ·:T - ., ~ P1ra qui problema(5)?.::s • • _ •• · ___ ~ ·• : : ·J

List any Vi tamins, Minerals, Herbs, Supplements you are taking on the next page. Lista de las vitaminas, minerales, hierbas y suplementos que usted esta tomando en lo pagina siguiente.

Eating Habits: (example: eating between meals, eat late, skip meals): Los habitos alimentarios: (por ejemplo: comer entre comidas, comer tarde, saltarse las comidas):

Drinking Habits: (example: drink w ith your meals; type of drinks: soda, liquor, juices, water) : Habitos de Consumo: (ejemplo: beber con las comidas; el tlpo de bebldas: soda, licores, Jugos, agua):

Family Medica l History I Historia medica familiar:

Have you ever tried alt ernative medicines (example - chiropractor, naturopathic, et c.) _ no _ yes. If yes, please list and for what problem.

l Ha lntentado alguna vez medicinas alternativas (por ejemplo, quiropractico, naturopathic, etc. ) _ No es si, por favor lista y para que problem a.

List any surgeries or procedures you had and when it was done. Lista de las cirugias o procedimientos que tenia y cuando se hizo.

List any Vitamins, Minerals, Herbs, Supplements you are toking Listo de las vitaminas, mineroles, hierbos y suplementos que usted est6 tomondo

Name of Vitamin, etc. / Nombre de la vltamlna, etc. --- Frequency I

Frecuencla

For What Problem(s)? Para qull problema(5)?

si . SI la respuesta

Are you currently under a doctor's care? _ No _ Yes. If yes, for what condition(s)? lEsta bajo los cuidados de un medico? _ No _ Si. Si la respucst a es sf, para que condlclon(es)7

Please provide the name and te lephone of a person to contact in case of emergency. Proporcione el nombre y telefono de la persona con la que contactar en ca so de emergencia.

Beacon of Hope\ CUent Questionnaire New and Revised 1/14/14 tn1llsh.ppt

Return this entire client health questionnaire with your deposit

VollH!r todo rstr cumlonarlo dr salud con su drp6slto

Page 4 of 4 I Pflgina 4 de 4

Checklist for Your Stay La lista de verificaci6n para su visita

Personal Loose clothing - enough for the length of your stay Pants Shirts I blouses Socks Sweater Sneakers or comfortable walking shoes change of under clothes Bathing suit (for hydrotherapy - if applicable) Robe Slippers Shower cap Pajamas Toothbrush & toothpaste Hair brush I comb Shampoo

Misc. notebook for notes pen or pencil Bible Favorite reading material Prescription glasses

--Sunglasses --Your medications

•Your medical supplies (glucose meter, strips, adult diapers and pads, cholesterol meter/strips, etc.)

Vitamins/supplements/herbs Current medical reports

-v (Spanish) Ropa Af/oje/floja - suficiente para el tiempo de su estancia pantalones Las camisas!blusas Ca/cetines I medias Sueter Zapatas c6modo para andar el cambio de bajo ropa El traje de bano (para la hidroterapia · si aplicable) Bata Zapatillas I chancletas Garro de bano Pijama El cep1/lo de dientes & la pasta dentifnca El cepillo def pelo I peina (peinilla) Champu

libro para notas pluma o el lapiz Biblia Material favorito para leer Gafas de prescripci6n Gafas de sol Sus medicinas Sus suministros medicos (metro de g/ucosa, las tiras, panales de adulto y a/mohadil/as, metro!tiras de co/estero/, elc.)

Las vitaminas!suplementalhierbas Reportes medicos actuates

You will be walking & possibly sweating, so bring changes of clothing Bring appropriate clothing based on time of year (summer, winter, etc.)

Usted estara andando & sudando posiblemente, asi que trae cambios de ropa. Traen ropa apropiada basada en la epoca def ano (el verano, el invierno, etc.)

Linens (towels and bedding) will be supplied by us Linos (foal/as y ropa de cama) sera suministrado par nosotros

• = There is an extra charge if our supplies are used •=Hay un recargo si nuestros suministros son utilizados

Pets are not allowed. Nose admiten animates Please do not bring your children unless they are going through the program.

Por favor haga arreg/os para sus nifJos mientras usted esta pasando por fa programa.

Personal \Checklist For Your Stay.xis l'CV. 10/20/14

Beacon of Hope R.L.C.

Beacon of Hope Rejuvenation lifestyle Center was founded by Jerry Jamel and Anna Rodriguez-Jamel

~

l 1 ..

Beacon of Hope was formed in 200 I with the intention of educating people as to the health principles which are built upon biblical understanding of health.

Beacon of Hope reaches out to people that are socially, physically, spiritually, chronologically, mentally and economically diverse, in the hope of making them aware of true health and teaching them to take responsibility for their own health and lifestyle.

We believe in dealing with the whole individual­physical, mental, emotional and spiritual. Therefore, our program and lectures are based on the person as a whole.

We at Beacon of Hope believe in the integration of

biblical counsel, medical research materials and variety of natural health principles. Using these methods to present the health message in a clear, easy-to-understand manner and in a step-by-step fashion, we believe all who participate in the program and lectures will benefit from a

healthy lifestyle.

It is our prayer that you will be richly blessed and that God will anoint you with the wisdom and power to make changes in your life in order to achieve optimum health and to lead others into that healing place.

What Dthers Are Saying ..... .

"The entire experience was truly remarkable. The retreat was a weekend getaway that really provided

me with so much insight that I would recommend anyone who wants to really feel energized to visit Beacon of Hope." (Arce/ M.)

"Their holistic approach to better health not only makes you a healthier person, but also educate you on how to maintain that ever so important habit of staying healthy. The atmosphere is incredibly

pleasant and private." (Karl G.)

'·Because of the Beacon of Hope Program, we have

decided to go on the vegetarian lifestyle diet and it is going very well. Anna and Jerry have been a great and positive influence in our lives." (Jeff & Lois H.)

Above all else, I want things to go well with you and for your body to be healthy as your soul.

3John 2

OO®@©©[fi) @fJ [}{)©~

lK1®]01JW®uu@UO©[fi)

~~~® ©@[fi)~@([

Every day that you invest in

your health, it will pay you back for

years to come !

Price List