womb surround process workshop application for returnees

Date/Location of Desired Workshop

Name

First Name

Last Name

Birthdate

Profession/Employment

Email Address

Primary Phone Number

What is Your Purpose for Taking this Workshop?

Some of the workshop techniques involve physical exertion. Do you have any medical conditions that would contraindicate involvement in such techniques? If yes, please explain.

Do you have any area of your body that needs special consideration? If yes, please explain.

Are you presently taking any medications or drugs? (name of medication, for what condition)

Are you presently using any recreational drugs, alcohol, nicotine, cannabis? (amount per day week)

Have you learned anything else that is significant to the process workshop method since your first attendance that we need to know about?

Please "x" the following in agreement to the terms:

I Agree to the Following:

Taking Responsibility for my well-being during and after the workshop.

Being in good physical, emotional and mental condition and able to participate in the regularly scheduled activities of the workshop

MAINTAINING CONFIDENTIALITY ABOUT WHAT UNFOLDS IN THE WORKSHOP

Attend All scheduled days; arrive on time to all parts of the workshop; fly in a day prior and leave the day after the workshop completes.

Complete all necessary payment of fees

Abstain from alcohol, recreational drugs and nicotine from the day before the workshop, during all breaks within the workshop, until the day after the workshop ends.

To refrain from wearing perfume, aromatherapy blends or strongly scented shampoos

Sexual behavior is only permitted between between participants who are attending the workshop as a couple.

Please Enter Your Name and Date You are Submitting this Form