Medical & Activity Agreement

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This field is for validation purposes and should be left unchanged.

Please carefully read & complete this form to confirm your attendance. It is compulsory that this document is completed at its most truthful and accurate form.

Your Name*

First Last

Preferred Name*

Your Email Address*

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Your Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Select Event you are crewing for*

Real Woman 1 - August 2026 Workshop

Real Man 1 - September 2026 Workshop

Real Woman 2 - October 2026 Workshop

Real Man 2 - November 2026 Workshop

Real Spiritual Quest - February 2027 Workshop

Real Tantra Aphrodite & Eros - May 2026 Workshop

Real Coach Program - March 2026 Workshop

Real Relationships - July 2026 Workshop

Are you crewing on the Same Gender team or the Opposite Gender team?*

Same Gender

Opposite Gender

Are you crewing on the Same Gender team or the Opposite Gender team?*

Same Gender

Opposite Gender

Are you Pregnant?*

Yes

Profession*

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Date of Birth*

You must be 18+ to attend this event.

Date of Birth*

You are ineligible to attend.

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Will you be under 7 months Pregnant at the time of the event?*

Yes

Pregnant Women cannot attend the event if they are 7 months or more at the time of the event

You are ineligible to attend.

As you indicated you are pregnant at the time of the event, you are unable to participate. Please click the submit button so we can be notified and follow up with you.

✓ Thank you. Our team has been notified and will follow up with you shortly.

The nature of this event requires you to take full responsibility for your physical and pregnancy wellbeing.

Declaration:

I understand and agree:

My Doctor will provide a Medical Clearance Certificate addressed to Real Education stating I am capable of attending this Real Education event.

I confirm that my Doctor has read Real Education's Activity Agreement.

Real Education will have to assess my Medical History Form and participation in this event no later than 2 weeks before the event commencement date.

Real Education will have to assess my Medical History Form and participation in this event no later than 2 weeks before the event commencement date.

Real Education holds the right to cancel my enrolment and 100% monies paid will be refunded, if Real Education deems the venue, facilities and/or processes are not suitable based on my condition.

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Doctors Clearance Certificate*

Max. file size: 64 MB.

1. Emergency Contact
a. "ICE" In Case of an Emergency

Emergency (ICE) Contact Name*

First & Last Name

Emergency (ICE) Contact Phone Number/s*

b. How is the person related to you?*

IE: Dad, Wife, Son, Friend

2. Psychosocial History

a. Have you been under the care with a Psychiatrist within the past 12 months?*

Yes

For all conditions except ADHD

Personal Responsibility Notice*

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

I understand and agree:

• Real Education will not be liable nor will they be held responsible for any loss, injury or the like that I may suffer directly or indirectly as a result of attending in the event..

• The event is not therapy, nor is it meant to be a substitute for any form of health care.

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

I understand and agree:

Real Education will not be liable nor will they be held responsible for any loss, injury or the like that I may suffer directly or indirectly as a result of attending in the event.
The event is not therapy, nor is it meant to be a substitute for any form of health care.

This field is hidden when viewing the form

2. Name of Psychiatrist*

b. Name of Psychiatrist*

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3. What is your condition and reason for seeing a Psychiatrist?*

c. What is your condition and reason for seeing a Psychiatrist?*

d. If you feel you will need a Medical Clearance Form, do so.*

Yes, I will need a Medical Clearance

No, I wont need a Medical Clearance

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

Psychiatrist Letter

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

I understand and agree:

• My psychiatrist will provide a Medical Clearance Certificate addressed to Real Education stating I am emotionally and mentally capable to attend this Real Education event.

• I confirm that my psychiatrist has read Real Education's Activity Agreement.

• Real Education will have to assess my Medical History Form and participation in this event no later than 2 weeks before the event commencement date.

• Real Education holds the right to cancel my enrolment and 100% monies paid will be refunded, if Real Education deem the venue, facilities and/or processes are not suitable for my specific needs or if in Real Education's discretion deem the event not appropriate for me.

3. Medical History

a. Do you consider yourself to have a substance addiction or psychological addiction?*

Yes

What specifically are you addicted to? [add additional information you think we might need to know]*

b. Do you have, or have you had, any of the following conditions or symptoms?*

None

Active Hepatitis

Hepatitis B

Hepatitis C

HIV

Medical Equip or Devices

Physically Disabled

Legally Blind

c. Did you answer yes to any of the above items?*

Yes

You answered YES to any of the above. Please provide details that we might need to know.*

d. Is there any other conditions we need to know about that is not listed above?*

4. Medication & Allergies

a. Are you taking any medications?*

Yes

As you answered YES, please advise details of medications you are taking.*

If you are currently on medication, and as a result of attending this event you want to go off your medication, you will need to first consult your doctor for a reduction management plan. Do not instantly stop taking your medication.

b. Do you have any medical allergies ? (eg: Allergic to Penicillin)*

Yes

You answered YES. Please provide details of your medical allergies.*

5. Dietary Allergies

a. Do you have any dietary allergies? (Eg: Celiac, Nut Allergy etc)*

Yes

You answered YES. Please provide details of your Dietary Allergies.*

Celiac

Dairy

Peanuts

Other

Other*

b. Please describe the reaction and response required.*

6. Dietary Preferences

a. Do you have any dietary preferences?*

Yes

b. You answered YES. Please advise your Dietary Preferences.**

Celiac

Dairy Free

Vegetarian

Vegan

Other

Other*

Your relevant information will be released to any medical personnel in the event you need urgent medical attention.

This field is hidden when viewing the form

By signing this Agreement, I confirm the contents of this document are true and correct.*

Please use your mouse to sign your signature

Date*

Phone

This field is for validation purposes and should be left unchanged.

Please carefully read & complete this form to confirm your attendance. It is compulsory that this document is completed at its most truthful and accurate form.

Your Name(Required)

First Last

Your Email Address(Required)

Your Address(Required)

This field is hidden when viewing the form

Your Address(Required)

Street Address City State / Province / Region

Select Event you are registering for(Required)

Real Woman 1 - August 2026 Workshop

Real Man 1 - April 2026 Workshop

Real Woman 2 - October 2026 Workshop

Real Man 1 - September 2026 Workshop

Real Man 2 - November 2026 Workshop

Real Tantra Aphrodite & Eros - May 2026 Workshop

Real Spiritual Quest - February 2027

Real Coach Program - March 2026 Workshop

Real Relationships - July 2026 Workshop

Are you Pregnant?(Required)

Yes

Profession(Required)

This field is hidden when viewing the form

Date of Birth(Required)

You must be 18+ to attend this event.

Date of Birth(Required)

You are ineligible to attend.

This field is hidden when viewing the form

Will you be under 7 months Pregnant at the time of the event?(Required)

Yes

Pregnant Women cannot attend the event if they are 7 months or more at the time of the event

You are ineligible to attend.

The nature of this event requires you to take full responsibility for your physical and pregnancy wellbeing.

Declaration:

I understand and agree:

My Doctor will provide a Medical Clearance Certificate addressed to Real Education stating I am capable of attending this Real Education event.

I confirm that my Doctor has read Real Education's Activity Agreement.

Real Education will have to assess my Medical History Form and participation in this event no later than 2 weeks before the event commencement date.

Real Education will have to assess my Medical History Form and participation in this event no later than 2 weeks before the event commencement date.

Real Education holds the right to cancel my enrolment and 100% monies paid will be refunded, if Real Education deems the venue, facilities and/or processes are not suitable based on my condition.

This field is hidden when viewing the form

Doctors Clearance Certificate(Required)

Max. file size: 64 MB.

1. Emergency Contact
a. "ICE" In Case of an Emergency

Emergency (ICE) Contact Name(Required)

First & Last Name

Emergency (ICE) Contact Phone Number/s(Required)

b. How is the person related to you?(Required)

IE: Dad, Wife, Son, Friend

2. Psychosocial History

a. Have you been under the care with a Psychiatrist within the past 12 months?(Required)

Yes

For all conditions except ADHD

Personal Responsibility Notice(Required)

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

I understand and agree:

• Real Education will not be liable nor will they be held responsible for any loss, injury or the like that I may suffer directly or indirectly as a result of attending in the event..

• The event is not therapy, nor is it meant to be a substitute for any form of health care.

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

I understand and agree:

Real Education will not be liable nor will they be held responsible for any loss, injury or the like that I may suffer directly or indirectly as a result of attending in the event.
The event is not therapy, nor is it meant to be a substitute for any form of health care.

This field is hidden when viewing the form

2. Name of Psychiatrist(Required)

b. Name of Psychiatrist(Required)

This field is hidden when viewing the form

3. What is your condition and reason for seeing a Psychiatrist?(Required)

c. What is your condition and reason for seeing a Psychiatrist?(Required)

d. If you feel you will need a Medical Clearance Form, do so.(Required)

Yes, I will need a Medical Clearance

No, I wont need a Medical Clearance

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

Psychiatrist Letter

Given the nature of this event, it is your responsibility to have an awareness of your condition so you can grant your own permission for eligibility.

I understand and agree:

• My psychiatrist will provide a Medical Clearance Certificate addressed to Real Education stating I am emotionally and mentally capable to attend this Real Education event.

• I confirm that my psychiatrist has read Real Education's Activity Agreement.

• Real Education will have to assess my Medical History Form and participation in this event no later than 2 weeks before the event commencement date.

3. Medical History

a. Do you consider yourself to have a substance addiction or psychological addiction?(Required)

Yes

What specifically are you addicted to? [add additional information you think we might need to know](Required)

b. Do you have, or have you had, any of the following conditions or symptoms?(Required)

Active Hepatitis

Hepatitis B

Hepatitis C

HIV

Medical Equip or Devices

Physically Disabled

Legally Blind

None

c. Did you answer yes to any of the above items?(Required)

Yes

You answered YES to any of the above. Please provide details that we might need to know.(Required)

d. Is there any other conditions we need to know about that is not listed above?(Required)

4. Medication & Allergies

a. Are you taking any medications?(Required)

Yes

As you answered YES, please advise details of medications you are taking.(Required)

b. Do you have any medical allergies ? (eg: Allergic to Penicillin)(Required)

Yes

You answered YES. Please provide details of your medical allergies.(Required)

5. Dietary Allergies

a. Do you have any dietary allergies? (Eg: Celiac, Nut Allergy etc)(Required)

Yes

You answered YES. Please provide details of your Dietary Allergies.(Required)

Celiac

Dairy

Peanuts

Other

Other(Required)

b. Please describe the reaction and response required.(Required)

6. Dietary Preferences

a. Do you have any dietary preferences?(Required)

Yes

b. You answered YES. Please advise your Dietary Preferences.*(Required)

Celiac

Dairy Free

Vegetarian

Vegan

Other

Other(Required)

Your relevant information will be released to any medical personnel in the event you need urgent medical attention.

This field is hidden when viewing the form

By signing this Agreement, I confirm the contents of this document are true and correct.(Required)

Please use your mouse to sign your signature

Date(Required)