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Layout(Office Use Only) The Landmark Forum Congratulations on having registered in The Landmark Forum. The Landmark Forum is an inquiry into
one's relationship to life—to one's self, family, teachers, school and peers. The Landmark Forum is designed as
an opportunity for people to be more powerful, freely expressed and effective in dealing with life.
Å The Landmark Forum for Young People Å The Landmark Forum for Teens • PARTICIPANT AND PARENTS: Each one of you will have sections of this form to complete. The information requested in
this form is intended to enable people to get the maximum results out of the three days of The Landmark Forum and beyond.
This information will be held in strictest confidence. All questions must be answered in full before your child can participate inThe Landmark Forum.
• Please print clearly in ink. Fill every space completely. When a question is not applicable, write N/A rather than leave it blank.
1. The Landmark Forum (City) Month Dates Year 2. Name (Last) (First) (Name I like to be called) 3. Home Address (Street / P.O. Box) City State / Province Zip / Postal Code 4. Home Phone ( ) 5. Age (as of Day 1 of the Course) Date of Birth (Month/Day/Year) Gender ÅMale ÅFemale 6. Have you (young person or teen) completed The Landmark Forum? ÅYes ÅNo 7. Please list the names and ages of siblings and friends who are also registered in this course with you.
Name Age Relationship Name Age Relationship Name Age Relationship Name Age Relationship 8. Please list the names and ages of siblings who are NOT registered in this course with you.
Name Age Relationship Name Age Relationship Name Age Relationship 9. If the participant has a mentor, please complete the following information: Mentor's name. Home Phone ( ) Work Phone ( ) Other Phone ( ) Participant's First and Last Name 10. Parent Name ÅMother ÅFather ÅLegal Guardian (Last) (First) Address (Street / P.O. Box) City State/Province Zip / Postal Code We require all phone numbers in the event of an emergency. For numbers you want us to use only in the event of an emergency, please write "Emerg Only" above that number.
Home Phone ( ) Work Phone ( ) Cell or Other Phone ( ) Have you completed The Landmark Forum? ÅYes ÅNo ÅRegistered ÅSingle ÅMarried ÅWidowed ÅSeparated ÅDivorced ÅDomestic Partnership Spouse / partner's name Has spouse/partner completed The Landmark Forum? ÅYes ÅNo 11. Parent Name ÅMother ÅFather ÅLegal Guardian (Last) (First) Address (Street / P.O. Box) City State/Province Zip / Postal Code We require all phone numbers in the event of an emergency. For numbers you want us to use only in the event of an emergency, please write "Emerg Only" above that number.
Home Phone ( ) Work Phone ( ) Cell or Other Phone ( ) Have you completed The Landmark Forum? ÅYes ÅNo ÅRegistered ÅSingle ÅMarried ÅWidowed ÅSeparated ÅDivorced ÅDomestic Partnership Spouse / partner's name Has spouse/partner completed The Landmark Forum? ÅYes ÅNo Parents: The following questions (12-15) are to be answered by you.
12. What physical or medical conditions does your child have that we should know about? a. ÅYes ÅNo Allergies? If yes, please specify b. ÅYes ÅNo Physician Diagnosed: Attention – Deficit If yes, please specify Disorder (ADD), Attention – Deficit/Hyperactivity Disorder (ADHD), or any other disorder? c. ÅYes ÅNo Special Condition (Physically Challenged, If yes, please specify Hypoglycemic, Hearing or Vision Impaired, or any medical or other condition?) IMPORTANT NOTE: We provide only one menu. If the participant has a special diet, has special food requirements of any nature, they will need to provide their own lunch. This food should be similar to what is on our menu and should not require refrigeration or preparation of any kind. The Registration Fulfillment Manager will provide you with a copy of the menu upon request. If the participant requires snacks, you will need to provide them. The vending machines will not be available during The Landmark Forum for Young People.
e. Should your child need to take any medication during the course, they will need to administer the medication themself, or their parent/legal guardian will need to come to the course to administer the medication. We will not administer epinephrine injections. If your child needs someone to administer an epinephrine injection, then a parent or legal guardian should remain on the premises during the course.
f. Medications: Please list any medications your child is taking and for what reason.
Participant's First and Last Name 13. Emergency Information: In case of an emergency in which your child incurs a serious injury or illness, the procedure
below will be followed:
1) We will call emergency medical services (United States – 911).
2) We will call you (the parents/legal guardians).
3) We will have your child transported to the nearest hospital emergency room if necessary.
THIS SECTION (Questions 14-15) IS TO BE COMPLETED BY THE PARENTS / LEGAL GUARDIANS ONLY.
14. In people's lives, the following areas are often potential sources for breakdowns, issues, and/or concerns: Relationships to: • Body, self, parents, siblings, peers, teachers
• Parents' separation, divorce or a death in the family
• Rules and agreements at home and school
In your own words, clearly state the specific issues, concerns, complaints, upsets and/or breakdowns your child is dealing with in his/her life in which your child may be stopped or limited. Please indicate who is the person responding: ÅMother ÅFather ÅStep-parent ÅLegal Guardian 15. How have the above impacted your child in being fully expressed, related, and effective in his/her everyday life? Please indicate who is the person responding: ÅMother ÅFather ÅStep-parent ÅLegal Guardian This section is to be completed by the participant.
In The Landmark Forum, we will be looking at what it is to be human. It is not about what's "wrong" with you and your life, but rather what is possible in your being an extraordinary human being and having a life you love. In order to get the most out of your participation in The Landmark Forum, you will need to take a moment to say what you intend to accomplish in at least three areas of your life.
You might consider your relationship to: • Yourself • Your brothers / sisters • Your schoolwork / teacher(s) • Your parents / authority • People your own age / classmates • Your chores / jobs / work What I intend to accomplish in The Landmark Forum is: (This is to be written in the participant's own handwriting.) Participant's First and Last Name NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS
You must read the section below carefully and completely.
1. We are pleased that you are going to participate in The Landmark Forum (the "Program"). Many people have found the Program to be an enjoyable and valuable experience. However, the Program is not advisable for everyone. The purpose of this Notice is toensure that you are not one of the people for whom this Program may be inadvisable.
We take our responsibility and your safety seriously. Please read each section of this Notice carefully and completely so you can make the right decision for yourself. The recommendations in this Notice have been made by mental health professionals whoadvise Landmark.
Although the number of people who have experienced serious problems during or after the Program is quite small, you should be certain whether the Program is appropriate for you. If you have any questions, please contact a mental health professional. Wewill assume from your participation in the Program and from your declaration at the end of this application that you have a fullunderstanding of each and every paragraph which follows and that you understand our recommendations and will comply withour instructions.
You and you alone are responsible for your choice to participate in the Program and for your own
health and well-being at all times prior to, during and after your participation in the Program.
2. The Program is a unique course of instruction designed to support people in being more effective in realizing their own personal and societal goals. Through a series of philosophically rigorous and open discussions, voluntary sharing of your experience andshort exercises, the Program provides an opportunity to explore basic questions that have been of interest to human beingsthroughout time and to examine many aspects of your own life. In the Program, people come to grips with what it means to behuman — not as a mere classroom exercise, but as a rigorous inquiry. The Program offers a unique technology through whichpeople create new possibilities for their lives. 3. In the Program, you will inquire into fundamental issues that have been of interest and concern to us as human beings. The experience of the Program is unique to each individual and there is no way to predict in advance exactly what you may think or feel. It is
normal for some people to experience unwanted or unfamiliar emotions from time to time, such as fear, anger, sadness, regret,
hatred, irritation and impatience. For most participants, exploring thoughts and feelings that they have not fully explored before is
a useful and positive learning experience. Some participants have found that exploring life's issues honestly may evoke uncomfortable
and unpleasant feelings. For others, the Program may occur as physically, mentally and emotionally seriously distressing. If you
are unwilling to encounter any of these powerful experiences in yourself or in others, or if you have any concern about your ability
to deal with such experiences, THE MENTAL HEALTH PROFESSIONALS WHO ADVISE LANDMARK ("OUR
ADVISORS") STRONGLY RECOMMEND THAT YOU DO NOT PARTICIPATE in the Program.
4. Some people experience temporary and not seriously consequential stress during and after the Program. For most people, stress is a normal part of everyday life. However, people who have a history of mental illness or serious emotional problems personally
or in their immediate family may be more vulnerable to stress and may experience additional and very severe physical, mental or
emotional problems. In people who have physical, mental or emotional problems, even normal amounts of stress from any source
may generate severe physical, mental or emotional problems. If you have any history of mental illness or emotional problems
personally or in your immediate family, whether temporary, occasional or intermittent, and whether treated or not, or have
concerns about your ability to handle stress, OUR ADVISORS STRONGLY RECOMMEND THAT YOU DO NOT
PARTICIPATE in the Program. If you are uncertain about whether this applies to you, we advise you to discuss this with a
mental health professional before participating in the Program.
5. While it is ultimately your choice, OUR ADVISORS STRONGLY RECOMMEND THAT YOU SHOULD NOT
PARTICIPATE in the Program if you:
(a) have a personal or family history of bi-polar affective disorder (manic-depressive disorder), schizophrenia, acute or chronic depression or other psychotic disorder, whether or not you or they are being or have ever been treated or hospitalized; (b) are taking, have taken or been prescribed to take within the previous twelve months anti-anxiety drugs (such as Librium, Ativan, Klonapin, Xanax, Dormicum or others); anti-depressants (such as Elavil, Prozac, Zoloft, Celexa, Cipram, Prothiadenor others); anti-psychotics (such as Thorazine, Haldol, Stelazine, Risperdal, Zyprexa, Dogmatil or others); any medicationto treat bi-polar disorders (such as Lithium, Gabapentin or Depakote); any drugs or medicines, whether prescription or non-prescription, intended to treat or affect mental processes or mood or to treat a chemical imbalance; or anabolic steroids; (c) have an unresolved history of drug or steroid abuse; (d) are or have in the past year been depressed and/or considered or had ideas of suicide, self-harm or harm to another; (e) are currently in therapy and your therapist sees a health reason why you should not participate in the Program; or (f) are uncertain about your physical, mental or emotional ability to participate in the Program.
Participant's First and Last Name NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS (continued)
6. From time to time, during or shortly after participating in the Program, a very small number of people who have no personal or family history of mental illness or drug abuse have reported experiencing brief, temporary episodes of emotional upset ranging from heightened activity, irregular or diminished sleep, to mild psychotic-like behavior. An even smaller number of people have reported more serious symptoms ranging from mild psychotic behavior to psychosis occasionally requiring medical care and hospitalization. In less than 1/1000 of 1% of participants, there have been reports of unexplained suicide or other destructive behavior. While we know of no independent studies to suggest that people who are physically, emotionally and mentally healthy are at risk in the Program, certain persons have claimed that the Program has caused or triggered in them a psychosis or psychotic event. 7. The Program is designed for people who clearly understand they are responsible for their own health and well-being
before, during and after the Program. It is not therapeutic in design, intent or methodology and is not to be used as a substitute
for medical treatment, psychotherapy or health program of any nature, regardless of what you may believe or have heard from anyone. We advise you that the Program Leaders, staff and people who assist at the Program are not mental health professionals and there will not be any mental health professionals in attendance. 8. If you experience any symptoms or suggestion of mental distress in the Program sessions, during the breaks or at the end of any session, or between sessions, you must immediately inform the Program Leader or the Program Supervisor. In such event, you and the Program Leader will discuss the matter and you will determine what is the appropriate thing for you to do. If you experience any symptoms or suggestions of mental distress outside of the Program, we strongly recommend that you immediately inform a physician or mental health professional.
9. While there are breaks in the Program, approximately every 2 to 3 hours, we do not promise that we will always break at precisely that interval. Each day there is one meal break and snacks are provided during the afternoon break. We suggest that you eat a meal before arriving at the beginning of each day. If you need to eat more frequently, then you should bring food with you. If you require special seating, must stand and stretch frequently, or have any other needs, please notify the Program Supervisor, Director, or Leader so that appropriate arrangements can be made.
10. If you have not been feeling well or if you have been meaning to see a physician or a mental health professional for some complaint, symptom or concern, or if you have had difficulty sleeping lately, or been depressed, it is imperative that you consult with a physician or mental health professional prior to your participating in the Program. Upon request, Landmark will provide you with information required to enable you to make an informed decision about your participation. 11. Although the schedule of the Program usually (but not always) accommodates sufficient time for sleeping, some participants have stated that they did not have sufficient time to sleep or were unable to sleep at night before, during or after the Program. Some people have entered the Program without having had sufficient sleep. For some people, lack of sleep can become a serious problem and may be symptomatic of a mental or emotional illness. If in the past you have become (or think that you may become) ill or seriously distressed because of lack of sleep, OUR ADVISORS STRONGLY RECOMMEND THAT YOU DO NOT
PARTICIPATE in the Program. If you do not have sufficient sleep or if you have a sleep disorder during the week before the
commencement of the Program, OUR ADVISORS STRONGLY RECOMMEND THAT YOU DO NOT PARTICIPATE
in the Program. If during the Program, you feel that you have been unable to sleep or have not had sufficient sleep, you must notify your Program Leader or Program Supervisor at once.
12. If, after your consulting with your medical or mental or health professional, your health professional needs any additional information about the Program in order to resolve your ability to participate, please contact the Registration Fulfillment Manager at the Center delivering this Program who will provide you with such information.
Participant's First and Last Name The following Agreements are intended to have legal significance. If you have any questions
about their meaning, please feel free to consult an attorney.
PARENT RELEASE STATEMENT
The purpose of this statement is to ensure the safety of participants. We recommend that parents themselves bring and pick up theirchild during The Landmark Forum. a. THE LANDMARK FORUM FOR YOUNG PEOPLE: I will be bringing and picking up
my young person for all sessions of the Program.
b. THE LANDMARK FORUM FOR YOUNG PEOPLE: If no, I give the following individuals permission to bring and/or pick
up my young person during the Program: A parent, legal guardian, or legal designate must sign-in with the young person each morning. A young person WILL NOT bereleased at the end of the day until an authorized person has signed a card for their release.
c. THE LANDMARK FORUM FOR TEENS: I give my teen permission to bring and dismiss
himself/herself. (NOTE: The response to this item, if on a young person's form, will be ignored.) THE LANDMARK FORUM FOR TEENS: We recommend that your teen remain on the premises during the hours of the course
for their own safety and to maximize their participation in The Landmark Forum. Landmark staff and the people who assist do not
manage whether your teen stays or leaves the premises. We operate with your teens on the honor system. Please inform your teen of
your choice in this matter. Please check the appropriate box below:
d. My teen should remain on the premises during the hours of the course. (NOTE: The response to this item, if on a young person's form, will be ignored.) I accept responsibility for the information in this statement and agree to hold Landmark, its employees and agents harmless from anyand all liability arising from these choices.
ARBITRATION AGREEMENT (U.S. ONLY)
I agree that any dispute, claim or controversy arising out of my participation in the Program (or any of its associated activities),including the interpretation, application, execution, performance or enforcement of any provision of this Agreement or concerningLandmark Worldwide LLC, its officers, managers, employees, agents, people who assist and /or other participants in the Program("Landmark") will be submitted to and determined by final and binding arbitration. This Agreement to arbitrate includes claims thatthere have been any wrongful acts or omissions in my registration in the Program and the warnings and disclosure, content or deliveryof the Program (or any of its associated activities) by Landmark. Any such dispute, claim or controversy shall not be determined bylawsuit or resort to any court process in any court of law or equity, except as applicable law provides for judicial review, confirmationand enforcement of arbitration proceedings and awards. Judgment upon any award rendered in arbitration may be entered in anycourt having competent jurisdiction and an application may be made to such court for an order of enforcement.
Such arbitration shall take place pursuant to the Commercial Rules of the American Arbitration Association ("AAA") then in effect inthe City of * and shall be expedited and conducted on successive days before three arbitrators, inaccordance with the rules of the AAA then in effect. (* Write in the name of the city in which the Landmark Center accountable for the Program is located.) I agree that if either party institutes any legal action in any Court not authorized herein, the other party shall be entitled to respondby demurrer or other appropriate response, shall not be required to answer any complaint, and shall be entitled to a dismissal of suchlegal action. The other party shall be entitled to an award in its favor for the amount of its actual fees and costs of suit. I understand that Landmark Worldwide LLC is a Delaware company and that this Agreement will be construed and governed by thelaws of the State of Delaware. This Agreement cannot be modified unless in writing signed by me and by Landmark.
I also agree that the time in which I may commence arbitration shall not be greater than ninety (90) days following the
occurrence of the event or events which is/are the subject of my claim or claims. I understand that if I fail to commence
arbitration within said ninety (90) days, I may be forever barred from making such claim or claims against Landmark.
I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT IN WHICH I FREELY GIVE UP MY RIGHT TO A
JURY OR COURT TRIAL.
Participant's First and Last Name I have carefully read the Notice of Important Information and Health Warnings and understand the recommendations andinstructions. I have been informed to my satisfaction by the person who introduced me to the Program or by a representative ofLandmark Worldwide ("Landmark") about the general content of the Program and I have had an opportunity to ask questionsabout anything I do not know or understand. I recognize that it is not possible for Landmark to describe everything that may occurduring the Program which generally consists of data presented by the Program Leader; the voluntary sharing of experiences byother participants; and guided exercises or processes.
I acknowledge and understand that the Program was designed for people who clearly understand they are responsible for theirown health and well-being before, during and after the Program and who wish to enhance their living skills. I represent that I amnot participating in the Program to handle any physical, mental or emotional problems and I fully understand that no portion ofthe Program is delivered or supervised by health professionals.
I am aware and understand that some people have personally perceived the Program to be physically, mentally and/or emotionallystressful to them. I have been informed that certain persons with no personal or family history of current or previous mental oremotional problems and no history of use of psychotropic or mood altering drugs reported having experienced psychotic episodesfollowing the Program.
I acknowledge and understand that I have been STRONGLY ADVISED NOT TO PARTICIPATE in the Program if:
(a) I have been diagnosed with an emotional or mental disorder, or if someone in my immediate family has a history of emotional or mental disorder; (b) I am using or have used psychotropic or mood altering drugs which are listed in the Notice of Important Information and Health Warnings above; (c) I am or have in the last year been depressed, contemplated suicide, self-harm or harm to another; (d) I have concerns about my ability to handle stress; (e) I have or may become ill or seriously disturbed because of lack of sleep or less sleep than I am accustomed to; (f) I am unwilling or unable to experience powerful emotions in myself or others; (g) I am currently in therapy and my therapist sees a health reason why I should not participate; or (h) I am uncertain about my physical, mental or emotional ability to participate in the Program.
I represent that: (a) I know of no reason that I should not participate in the Program; (b) I have considered the nature of the Program and have voluntarily chosen to attend and not as a result of coercion, pressure, a condition of employment or to satisfy anyone other than myself; (c) I am fully aware of what I am undertaking and that there may be risks associated with the Program. I agree that I am responsible for my own participation in the Program and for my own physical, mental and emotional well being, and that Landmark isresponsible solely for the orderly presentation of the Program; and (d) I willingly and knowingly assume for myself, my family members, executors, administrators, heirs, successors, legal representatives and assigns all risks of physical and mental or emotional injuries which may occur during or after the Program.
I agree to inform and discuss with the Program Leader or Program Supervisor immediately if at any time before the Program iscompleted, I experience any unusual physical sensation or pain or any mental or emotional discomfort. If, following the completionof the Program, I experience any unusual physical sensation or pain or any mental or emotional discomfort, I agree to notify theManager of the Landmark Center which delivered the Program. I hereby indemnify and hold Landmark, its officers, managers, shareholders, affiliates, employees, agents and/or people who assistharmless from all loss, cost, obligation or damage arising out of my participation in the Program or in other activities or eventsrelated to the Program.
The failure of Landmark to enforce any of its rights shall not be construed as a waiver of any of its rights at any time thereafter. Ifany part or parts of this Agreement shall be deemed invalid or unenforceable, then that part or parts shall be deemed severed fromthis Agreement and such severance shall not have any effect on the remaining portions of the Agreement.
I acknowledge that my representations and agreements are freely given and are true to the best of my knowledge and are intendedto be an inducement to Landmark to approve my participation in the Program. HARASSMENT POLICY
Landmark Worldwide ("Landmark") is committed to providing an environment free from sexual or other forms of harassment.
Any harassment is unlawful and will not be tolerated by Landmark. If you believe you or your child has been unlawfully harassed,
you should contact the local Center Manager, or the Director of Human Resources at Landmark's World Headquarters in San
Francisco (at 415-616-2401). If you have any questions about Landmark's Harassment Policy or would like a copy of the Policy,
please contact either of these people.
Participant's First and Last Name SHARED LEGAL RIGHTS (Parents – Please read this very carefully and complete the appropriate section below:)
In order to participate in The Landmark Forum, we require the signature of anyone who has legal rights regarding the participant,
regardless of their marital status. Anyone who has any legal rights of a minor child must sign below. In the case where the legal rights
are not shared, the appropriate parent or legal guardian should complete the lower portion of this form. Please call the Center if you
have any questions regarding this.
MARRIED PARENTS OR PARENTS/GUARDIANS WITH SHARED LEGAL RIGHTS:
I GIVE PERMISSION FOR MY CHILD TO BE IN THE LANDMARK FORUM. I ACKNOWLEDGE THAT I HAVE
READ, UNDERSTAND AND AGREE TO COMPLY WITH THE ABOVE NOTICE OF IMPORTANT INFORMATION
AND HEALTH WARNINGS, PARENT RELEASE STATEMENT, ARBITRATION AGREEMENT (U.S. ONLY), AND
INFORMED CONSENT, ON MY CHILD'S BEHALF.
I agree that my signature on a faxed copy of this document shall be deemed an original.
Parent/Legal Guardian Signature Please print Parent/Legal Guardian's name here: I agree that my signature on a faxed copy of this document shall be deemed an original.
Parent/Legal Guardian Signature Please print Parent/Legal Guardian's name here: PARENT/GUARDIAN HAVING SOLE LEGAL RIGHTS:
I HAVE SOLE LEGAL RIGHTS REGARDING MY CHILD AND GIVE PERMISSION FOR HIM/HER TO BE IN THE
LANDMARK FORUM, AND I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO COMPLY
WITH THE ABOVE NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS, PARENT RELEASE
STATEMENT, ARBITRATION AGREEMENT (U.S. ONLY), AND INFORMED CONSENT, ON MY CHILD'S BEHALF.
I agree that my signature on a faxed copy of this document shall be deemed an original.
Parent/Legal Guardian Signature Please print Parent/Legal Guardian's name here: I understand that The Landmark Forum is a private and personal experience for each person who participates. I agree to respect theprivacy of all participants and the things they say and do, and I agree to keep all such information private and confidential. I have beeninformed that in order for me to receive the results of the Program, my participation must be an expression of my own free choice. Irepresent that I am participating in the Program voluntarily and not as a result of coercion, pressure, or to satisfy anyone other thanmyself. I AGREE TO ABIDE BY THE ABOVE NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS,
PARENT RELEASE STATEMENT, ARBITRATION AGREEMENT (U.S. ONLY), AND INFORMED CONSENT, AS
WELL AS THE PARAGRAPH ABOVE.
I agree that my signature on a faxed copy of this document shall be deemed an original.
Participant's Signature 2005–2013 Landmark Worldwide www.landmarkworldwide.com
REF. 9). Iproniazid, a drug registered for the treatment of tuberculosis, was found to elevate the mood of patients that received it,and subsequent studies in patients who were Is mood chemistry? depressed but did not have tuberculosisshowed its effect as an antidepressant9. Sim-ultaneously and independently, imipramine, Eero Castrén an experimental antihistamine with a tricyclicstructure, was found to have antidepressant