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.) To register electronically, click here. 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? None of the above. Signature ________________________________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? _____________________ I am paying via a check ___, PayPal___, or a credit card___. West Coast - Harbin Hot Springs, Middletown, CA East Coast - The Lodge at Sleepy Creek, Berkeley Springs, WV Healing the Mother Wound® Women 10/1-4; Men 10/15-18 Healing the Father Wound® Women 9/10-13; Men 9/16-19 Clearing the Air™ Between Women & Men 10/26-31 Healing the Father Wound® Women 9/30-10/3 Men 9/23-26 I can't make any of these. Put me on the mailing list. 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. To register for Healing the Mother Wound ($650) By mail: Make check payable to Shauna Wilson Mora and mail it to PO Box 60894, Palo Alto, CA 94386. For PayPal, call 650-351-8210. To register for Healing the Father Wound ($650) or Clearing the Air Between Women & Men ($995): By mail : Make check payable to Gordon Clay and mail to PO Box 1080, Brookings, OR 97415 Click here for PayPal. To pay with a credit card, leave the following information as a message or a fax sent to 541-469-5124: the type (Visa, Master Card or American Express only), the name as it appears on the card, the 16-digit number and the expiration date. Always let us know via e-mail when you are registering by snail mail or fax since we are often on the road and don't get the information immediately. For questions contact us here