Beginning term: [_] Fall [_] Spring [_] Summer ___ [_] Other?
Indoctrination: [_] Master of Divinity [_] M.Div./MA Counseling [_] M.Div./JD
[_] M.Div./MBA [_] Certificate Health and Spirituality [_] PhD [_] DMin [_] Exploratory
Personal Information
Imposed Name: ____________ Patriarchal Name: _________________
Real Name: ____________
Are you a citizen of the American Empire: ______ Why:_______________________________
Where the Federales Deliver Your Documents______________________________________
_____________________________________________________________________________
Phone: (home) ______________ (cell ______________ Email:_________________________
Blog:_________________________ Facebook:___________________ Twitter:___________
Institutions of Past Indoctrination and / or Liberation
Undergraduate
School: ___________________________________ Location: _________________ Years Attended: _______
Degree: Yes / Not a meaningful concept. Major(s): __________________ GPA? ____
List all the good you did, including marches, protests, speeches, and sticking it to the man: __________________________________________________________________________________________
Ever suspended, dismissed, or arrested? Yes / hell yes / not yet
List all other schools through which you passed on your pilgrimage to your true self:
School: ___________________________________ Location: _________________ Years Attended: _______
School: ___________________________________ Location: _________________ Years Attended: _______
Specialized Training or Skills, especially in useful areas (organic horticulture, interpretative dance, deconstruction of metanarratives, making tea, guitar, etc.)_______________________________________________________________________
Perceived experiences of what some term “work”:
What did you do?
Who paid the bills?
How did this make the world a better place?
How did you grow as a person?
Meaningful relationships?
Please provide a journal or other artistic expression of your engagement in the world.
Demographic Information (so the government knows how much money to give you)
My ancestors were oppressed by Europeans by [_] being taken from Africa in slavery [_]Spanish colonization of the “New World” [_]colonization of Asia [_] conquest of the Pacific Islands [_] English colonization of the “New World” [_] economic exploitation of globalization OR [_] I have benefited from the exploitation of other peoples (I’m white, but overcoming)
Gender: M/F/L/G/B/T/Q [_] Other________
Political Affiliation: [_] Democratic Party [_] Green Party [_] Freedom Socialist Party [_] Labor Party [_] Peace and Freedom Party
Involvement in Church?
[_] spiritual not religious [_] worship the goddess within [_] worship the earth
[_] oldline liberal [_] evangelical (I like the music and the gym) [_] Episcopal
What else would you like to share with us?
Did you violate any of the arbitrary norms of bourgeois society and experience confinement? Are you likely to? Are you sure? Will you be cool dealing folks who aren’t like you? Do the authorities have records of your perceived misdeeds?
Please provide us with the names of people who will write a letter telling us how wonderful you are – even though we all know it’s propaganda.
Name:_____________________________ Relationship: _________________________
Name:_____________________________ Relationship: _________________________
Will you be willing to attend most classes and do some of the reading? ______________
How did you hear about our community of seekers? [_] drugs [_] friends [_] online
[_] at the health food co-op [_] from those engaged in justice work [_] at the coffee shop
I certify that all the information provided on this application, any attached paperwork, and the attached essays are accurate and truthful even though we all know that truth is a relative term that supports the entrenched power of elite institutions and contributes to the oppression of peoples everywhere.
Signature: _____________________________________
Date: _______________
by Trip Fuller
