Test Page New Crew Medical History Form 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)Select Event you are registering for(Required) Real Woman 1 – March 2026 Workshop Real Man 1 – April 2026 Workshop Real Spiritual Quest – December 2025 Workshop Real Woman 2 – October 2026 Workshop Real Man 2 – November 2026 Workshop Real Tantra Aphrodite & Eros – May 2026 Workshop Real Coach Program – March 2026 Workshop Real Relationships – July 2026 Workshop Will you be eligible to crew on the Same Gender team or the Opposite Gender team?(Required) Same Gender Opposite Gender Are you Pregnant?(Required) Yes No Profession(Required)Date of Birth(Required) DD slash MM slash YYYY You are ineligible to attend.1. Emergency Contact a. “ICE” In Case of an EmergencyEmergency (ICE) Contact Name(Required)First & Last NameEmergency (ICE) Contact Phone Number/s(Required)b. How is the person related to you?(Required)IE: Dad, Wife, Son, Friend2. Psychosocial Historya. Have you been under the care with a Psychiatrist within the past 12 months?(Required) Yes No 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. b. Name of 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 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 Historya. Do you consider yourself to have a substance addiction or psychological addiction?(Required) Yes No 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 No 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 & Allergiesa. Are you taking any medications?(Required) Yes No As you answered YES, please advise details of medications you are taking.(Required)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)(Required) Yes No You answered YES. Please provide details of your medical allergies.(Required)5. Dietary Allergiesa. Do you have any dietary allergies? (Eg: Celiac, Nut Allergy etc)(Required) Yes No 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 Preferencesa. Do you have any dietary preferences?(Required) Yes No b. You answered YES. Please advise your Dietary Preferences.*(Required) Celiac Dairy Free Vegetarian Vegan Other Other(Required)Date(Required) MM slash DD slash YYYY
