CTA Workshops Registration Form Contraindications and Medical Information CTA Workshops are intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. They can involve dramatic experiences accompanied by strong release. Contraindications mean that these workshops are not appropriate for pregnant women, persons with cardiovascular problems, severe hypertension, mental illness, recent surgery or fractures, acute infectious illness, or epilepsy. If you have any doubt about whether you should participate, consult your physician and/or therapist as well as the facilitator well before attending. The answers to the following questions are to assist your facilitator and will be kept strictly confidential. Please answer all questions as completely as possible and return this form at your earliest convenience. Do you have a past or current history from any of the following? If yes, please elaborate fully on the back of this form.) Cardiovascular disease, heart attacks, strokes, high blood pressure Severe Hypertension Mental Illness Recent surgery Physical injuries, including fractures or dislocations Recent or current infectious or communicable diseases Epilepsy Glaucoma Retinal detachment Osteoporosis Asthma Severe allergic reactions Are you currently pregnant? Are you currently in therapy or any type of support group Are you currently taking any type of medication? What? Is there anything else about your physical or emotional status we should know? Signature _________________________________________ Signature for electronic filing only (By checking this box you declare that the information you have provided is true and correct.) Print Name______________________________________________________ Today's Date _________________________ Address____________________________________________________________________________________________ City_____________________________________________________ State __ Zip Code ___________________________ Home Phone _____________________ Office Phone __________________ Cell Phone _____________________________ E-mail ______________________________________________________________ Birth Date_______________________ I would like ride-share information: I can drive_____; I would like a ride from ________________________________________ I need transportation from the _______________Airport. Airline_____________ Flight # _____ Arrives ___________ (It's best to arrive between noon and 2pm on the first day and not leave until after 10pm on the last day or the next day.) I have completed an MKP__; Woman Within__; WIP__; HAI__ workshop. Date: ______ and Place _____________________ I am in therapy. My therapist's name and phone are ____________________________ Phone______________________ I heard about the workshops through _______________________Who got me to actually sign-up? _____________________ West Coast East Coast Healing the Mother Wound® Men 4/17-20/09 Healing the Father Wound® Women 4/24-27 Healing the Father Wound® Men 4/30-5/3 Healing the Mother Wound® Women 5/15-18 Clearing the Air™ Between Women & Men 10/27-11/1 I can't make any of these. Put me on the mailing list. Healing the Mother Wound® Women 3/19-22/09 Clearing the Air™ Between Women & Men 3/24-29 Healing the Father Wound® Women 5/7-10 Healing the Father Wound® Men 5/14-17 Healing the Mother Wound® Men 6/11-14 I would like to re-take this workshop at half-price *. * The half-price offer is available to past participants to retake a workshop. Each workshop is limited to 12 participants. Priority is given to the earliest postmark with full payment. When registering, please read, sign and submit this form with your payment. Make check or money order (not WalMart MoneyGram) payable and send: For Healing the Father Wound ($650) or Clearing the Air Between Women and Men ($995): By snail mail :Gordon Clay, PO Box 1080, Brookings, OR 97415 or to make your payment via credit card, send a fax to 541.469.5124. Include the type of credit card (Visa or MasterCard), the name as it appears on the credit card, the credit card number, the expiration date and the 3 digit code on the back. Always let us know via e-mail that you are registering by snail mail or fax since we are often on the road and don't get the information immediately. For Healing the Mother Wound ($650) By snail mail: Shauna Wilson Mora, PO Box 60894, Palo Alto, CA 94386 or PayPal call 650-351-8210 or contact Shuna here. For questions contact us here