Name: ____________________________________
(Feel free to use popular nicknames, such as "Moon Beam", "Dweezil",
"Moon Unit" "Capt. Trips", etc.)

Age: _____

Inner Child's Age: ___

Age in Dog Years: ____

Age as told to you in a vision by ancient Mayan calendar: ____

Sex:
_____ M
_____ F
_____ Hermaphrodite
_____ Still working it out in therapy

Footwear: ____ Birkenstocks ____ Barefoot

Condition of Feet:
____ Wash Daily
____ Wash Weekly
____ Like, whenever I get to the beach, man...

Occupation:
___ Massage Therapist
___ Astral Counsel
___ Pet Psychologist
___ Channeler of the Dead (real dead, not merely Grateful)
___ Follower of the Dead, (Grateful)
___ Tie-dye vendor at Dead Shows
___ Vendor of "nice hot, fresh veggie burritos" at concerts
___ Cooking up a scheme to channel Jerry Garcia
___ Assistant to Shirley MacLaine
___ Rent-A-Mob protester
___ Purveyor of Fine Herbal Remedies
___ Panhandler claiming to be a veteran
___ Professional Guest on Ricki Lake
___ LA rock star groupie
___ Bottom-feeding LA lawyer
___ Professional Emotional Victim

Name(s) of Significant Other(s): ________________________________

Relationship(s) of Significant Other(s):
____ Astral Soulmate
____ One-night stand from the protest rally who stayed because the
rent was cheap
____ My dog's massage therapist
____ "Just Friends"
____ They're really not that significant, but I'll try to claim them
as tax deduction(s)

Number of Children in Commune: _____

Number of Inner Children In Commune: _____

Number of your Inner Children which have been molested by one of
Roseanne's multiple personalities: ____

Mother's Name: ____________________

Father's Name: ____________________

Where were you were conceived:
____ Woodstock
____ Monterey
____ Under the stars on in the commune's hot tub
____ In the back of a VW micro-bus on the way to a Dead show

Name of book exposing your parents as inner-child abusers:
__________________

Number of copies sold: ____

Number of Wind Chimes Owned: ____

Number of times you've given yourself a concussion by hitting head
on wind chimes: ___

Number of time you've channeled dead space aliens: ____

Number of times a space alien has copped a feel off you: ____

Talk Shows on Which You Make a Regular Appearance:
____ Donahue
____ Ricki Lake
____ Geraldo
____ Sally Jesse
____ The morning news' surf report

Number of times you've eaten your surfboard: ____

Above, while still in parking lot after tripping on your sandals: ____

Number of Grateful Dead concerts attended: ____
(if all, enter "on tour")

Number of bongs you own: ____

Number of times you've drunk your bong water because the weed
ran out: ____

Political Party Affiliation:  (Choose as many as you have
personalities)
____ Green Party
____ American Communist Party
____ Socialist Party
____ New Age Astral Party (channeling the spirits of dead Romans)
____ Hemp Party
____ The Party-Hearty Party
____ Inner Child Abuse Hotline Party
____ New Age Goddess Party

How far is your home from the waterline:
___ Miles
___ Yards
___ Feet
___ I like to wake up with sand in my nose and seaweed in my teeth,
in true harmony with nature as it washes up my nose

Number of surfboards owned: ____

Number of seconds you can talk without using the words "totally",
"like", "man" and "fer shure": ____ (enter, like 0, if you, like,
totally don't know)