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The Landmark Forum
Congratulations on having registered in The Landmark Forum. We have designed The Landmark
Forum as an opportunity for people to advance their goals and commitments, to enhance their personal
effectiveness, and to achieve consistently extraordinary results.
* Please fill out this form completely and return it in the enclosed envelope within one week of receipt.
* The accuracy and completeness of your answers are important as a condition to your participation in this programme.
We will hold the information on this form in confidence.
* Please print clearly in ink and answer every question, and please sign your name in the appropriate place.
1.
The Landmark Forum (City)
Month
Dates
Year
2.
Name (Last)
(First)
(Middle)
(Name I like to be called)
3.
Home Address (Street / P.O. Box)
City/Town
Postal Code
Country
4. Home Phone ( )
Work Phone ( )
Mobile Phone ( )
5.
Age
Date of Birth (Day/Month/Year)
Sex
M
F
City / Town of Birth
If you are under 18 years of age, you must currently live at least 50% of the time with a parent or guardian who has completed The Landmark Forum.
6.
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partnership
7.
a. Please indicate your occupation or profession:
b. What is your job title or position?
8.
Have you completed The Landmark Forum?
Yes
No
If yes, where and when?
City
Month
Year
9.
Name of the person who introduced you to The Landmark Forum: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
10.
Please list the names of all family members, relatives, friends, and business associates who are participating in The Landmark Forum with you.
Name ______________________________________________________
Relationship to You ______________________________________________________
Name ______________________________________________________
Relationship to You ______________________________________________________
Name ______________________________________________________
Relationship to You ______________________________________________________
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To help you to benefit fully from your participation in The Landmark Forum, we ask that you take a moment to state specifically what you
intend to accomplish. Answering this question does not suggest or guarantee that you will achieve these specific results by the end of the
programme. However, by being specific, you will facilitate your participation. Please print your answer in the space provided below.
(You may attach additional pages if needed.)
11. What do you intend to accomplish?
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 "Programme"). Many people have found the
Programme to be an enjoyable and valuable experience. However, the Programme is not advisable for everyone. The
purpose of this Notice is to ensure that you are not one of the people for whom this Programme 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
who advise Landmark Education.
Although the number of people who have experienced serious problems during or after the Programme is quite small, you
should be certain whether the Programme is appropriate for you. If you have any questions, please contact a mental health
professional. We will assume from your participation in the Programme and from your declaration at the end of this
application that you have a full understanding of each and every paragraph which follows and that you understand our
recommendations and will comply with our instructions.
You and you alone are responsible for your choice to participate in the Programme and for
your own health and well-being at all times prior to, during and after your participation in the
Programme.
2. The Programme is a unique course of instruction designed to support people in being more effective in realising their own
personal and societal goals. Through a series of philosophically rigorous and open discussions, voluntary sharing of your
experience and short exercises, the Programme provides an opportunity to explore basic questions that have been of
interest to human beings throughout time and to examine many aspects of your own life. In the Programme, people come
to grips with what it means to be human -- not as a mere classroom exercise, but as a rigorous enquiry. The Programme
offers a unique technology through which people create new possibilities for their lives.
3. In the Programme, you will enquire into fundamental issues that have been of interest and concern to us as human beings.
The experience of the Programme 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 Programme 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 EDUCATION ("OUR ADVISORS") STRONGLY
RECOMMEND THAT YOU DO NOT PARTICIPATE in the Programme.
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NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS (continued)
4. Some people experience temporary and not seriously consequential stress during and after the Programme. 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 intermit-
tent, 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 Programme. 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 Programme.
5. While it is ultimately your choice, OUR ADVISORS STRONGLY RECOMMEND THAT YOU SHOULD NOT
PARTICIPATE in the Programme 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 hos-
pitalised;
(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, Prothiaden or others); anti-psychotics (such as Thorazine, Haldol, Stelazine, Risperdal, Zyprexa, Dogmatil or
others); any medication to 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 Programme; or
(f) are uncertain about your physical, mental or emotional ability to participate in the Programme.
6. From time to time, during or shortly after participating in the Programme, 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 hospitalisation. 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 Programme, certain persons have claimed that the Programme has
caused or triggered in them a psychosis or psychotic event.
7. The Programme is designed for people who clearly understand they are responsible for their own health and well-
being before, during and after the Programme. It is not therapeutic in design, intent or methodology and is not to be
used as a substitute for medical treatment, psychotherapy or health programme of any nature, regardless of what you may
believe or have heard from anyone. We advise you that the Programme Leaders, staff and people who assist at the
Programme 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 Programme sessions, during the breaks or at the end
of any session, or between sessions, you must immediately inform the Programme Leader or the Programme Supervisor. In
such event, you and the Programme 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 Programme, we strongly
recommend that you immediately inform a physician or mental health professional.
9. While there are breaks in the Programme approximately every 2 to 3 hours, we do not promise that we will always break at
precisely that interval. You are, of course, free to leave the Programme room at any time. Each day there is one meal break
in the late afternoon or early evening, usually lasting about an hour and a half. We suggest that you eat a meal before
arriving at the beginning of each day, and have a third meal or snack after you leave in the evening. You are welcome to
bring snacks to eat during other short breaks in the Programme. If you have a medical condition requiring you to eat or
care for some special need more frequently than the regularly scheduled breaks, or need special seating or must stand and
stretch frequently or have any other special needs, please notify the Programme Supervisor before the Programme begins
so that appropriate arrangements can be made for you.
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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 Programme. 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 Programme 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
Programme. Some people have entered the Programme 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 Programme. If you do not have sufficient sleep or if you have a sleep
disorder during the week before the commencement of the Programme, OUR ADVISORS STRONGLY RECOMMEND
THAT YOU DO NOT PARTICIPATE in the Programme. If during the Programme, you feel that you have been unable
to sleep or have not had sufficient sleep, you must notify your Programme Leader or Programme 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 Programme in order to resolve your ability to participate, please contact the Registration Fulfillment
Manager at the Centre delivering this Programme who will provide you with such information.
AGREEMENTS
The following Agreements are intended to have legal significance. If you have any
questions about their meaning, please feel free to consult a licensed legal professional.
CONFIDENTIALITY AGREEMENT
In order to promote and respect the confidentiality of our participants and our intellectual property, please read and sign
the following:
I understand that The Landmark Forum (the "Programme") is limited to people who have registered in the Programme.
In consideration of and as a condition for permitting my participation in the Programme, I represent, covenant, warrant and
agree that:
(a) I have registered in the Programme under my own name for the sole purpose of participating in the Programme;
(b) I will not publish, broadcast or disclose or assist another person or organisation in publishing, broadcasting or disclosing
the identity, likeness or actual or paraphrased comments, of other participants in the Programme, Staff or people who
assist during the Programme; and
(c) I will not film, videotape, audiotape or otherwise record, by electronic, digital or any other means, all or any portion of
the Programme, and I will not record or take pictures, or assist another person or organisation in recording and/or
taking pictures of any kind or nature, of all or any portion of the Programme or of any participants in the Programme,
Staff or people who assist in the Programme without the prior written permission of Landmark Education. I will not take
into the Programme room a tape or video recorder, movie or still camera, or any device, electronic or otherwise,
intended to record the voice or likeness of any person in the Programme room.
I further agree that the provisions of this Agreement shall be enforceable under the laws of the country in which I participate in
the Programme, and my breach of this Agreement shall constitute, among other things, a breach of contract and trespass for
which Landmark Education shall have the right to full legal and equitable recourse, including injunctive or other extraordinary
relief and damages. Any unenforceable portion of this Agreement shall not affect the remainder.
I recognise that my breach of this Agreement may cause Landmark Education and/or the participants in the Programme
irreparable and substantial harm even though it may be impossible to ascertain the full monetary extent of their financial loss.
Nothing in this Confidentiality Agreement is intended to limit you from sharing your experience of the Programme
with anyone.
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AGREEMENTS (continued)
PROPRIETARY MATERIALS AGREEMENT
I understand that all materials, concepts, and information (collectively "Materials") presented by Landmark Education
("Landmark") during this Programme, either orally or in writing, are the property of Landmark and are protected by copyright,
trade secret, and other applicable laws. I acknowledge that the Materials constitute commercially valuable, proprietary, confidential
property of Landmark, the design and development of which required the investment of substantial effort, time, and money.
All rights in the Programme and the Materials are expressly reserved by Landmark. I agree not to reproduce, copy, or otherwise
duplicate, and not to distribute, lend, or otherwise transfer, the Materials without the prior written permission of Landmark.
I agree not to use the Materials in any way that would compromise the confidential and proprietary nature of the Materials.
I understand that the Materials presented by Landmark in this Programme are intended solely for use in the Programme.
I understand that while I am free to use the Materials for my own personal use, and free to tell others about the benefits I realised
from the Programme, I agree not to resell, reproduce and sell, modify and sell, or repackage and sell the Materials. I agree that
I will not use the Materials for any purpose other than my own personal use except with the prior written permission of
Landmark. I agree not to deliver the Materials themselves, either reproduced or modified, or anything derived from the
Materials, either orally or in writing, as part of any seminar, training programme, workshop, consulting, or similar business
activity which I make available to my clients or to others, except with the prior written permission of Landmark.
I agree that this Agreement supersedes any prior agreements I may have regarding the use of the Materials and that, if
necessary, I will again obtain Landmark's written permission before using any materials which I may have obtained permission
to use in the past.
INFORMED CONSENT
I have carefully read the Notice of Important Information and Health Warnings and understand the recommendations and
instructions. I have been informed to my satisfaction by the person who introduced me to the Programme or by a representa-
tive of Landmark Education about the general content of the Programme and I have had an opportunity to ask questions about
anything I do not know or understand. I recognise that it is not possible for Landmark to describe everything that may occur
during the Programme which generally consists of data presented by the Programme Leader; the voluntary sharing of
experiences by other participants; and guided exercises or processes.
I acknowledge and understand that the Programme was designed for people who clearly understand they are responsible for their
own health and well-being before, during and after the Programme and who wish to enhance their living skills. I represent that
I am not participating in the Programme to handle any physical, mental or emotional problems and I fully understand that no
portion of the Programme is delivered or supervised by health professionals.
I am aware and understand that some people have personally perceived the Programme to be physically, mentally and/or
emotionally stressful to them. I have been informed that certain persons with no personal or family history of current or
previous mental or emotional problems and no history of use of psychotropic or mood altering drugs reported having
experienced psychotic episodes following the Programme.
I acknowledge and understand that I have been STRONGLY ADVISED NOT TO PARTICIPATE in the Programme 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 Programme
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AGREEMENTS (continued)
I represent that:
(a) I know of no reason that I should not participate in the Programme;
(b) I have considered the nature of the Programme 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 Programme. I agree that I
am responsible for my own participation in the Programme and for my own physical, mental and emotional well
being, and that Landmark Education is responsible solely for the orderly presentation of the Programme; 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
Programme.
I agree to inform and discuss with the Programme Leader or Programme Supervisor immediately if at any time before the
Programme is completed, I experience any unusual physical sensation or pain or any mental or emotional discomfort. If,
following the completion of the Programme, I experience any unusual physical sensation or pain or any mental or emotion-
al discomfort, I agree to notify the Manager of the Landmark Education Centre which delivered the Programme.
I hereby indemnify and hold Landmark Education, its officers, managers, shareholders, affiliates, employees, agents and/or
people who assist, harmless from all loss, cost, obligation or damage arising out of my participation in the Programme or in
other activities or events related to the Programme.
The failure of Landmark Education to enforce any of its rights shall not be construed as a waiver of any of its rights at any
time thereafter. If any part or parts of this Agreement shall be deemed invalid or unenforceable, then that part or parts shall
be deemed severed from this 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
intended to be an inducement to Landmark Education to approve my participation in the Programme.
I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO COMPLY WITH THE
NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS, CONFIDENTIALITY
AGREEMENT, PROPRIETARY MATERIALS AGREEMENT AND INFORMED CONSENT.
I agree that my signature on a faxed copy of this document shall be deemed an original.
Signature
Date
If you are under 18 years of age, your parent or legal guardian must read and sign below:
ALL PARENTS OR LEGAL GUARDIANS WHO SHARE LEGAL CUSTODY OF THE ABOVE-NAMED MINOR MUST SIGN BELOW IN ORDER FOR
THE ABOVE-NAMED MINOR TO PARTICIPATE IN THE LANDMARK FORUM.
AS PARENTS OR LEGAL GUARDIANS OF THE ABOVE-NAMED MINOR:
1. WE/I HAVE GIVEN OUR/MY PERMISSION FOR THE ABOVE-NAMED MINOR TO TAKE THE LANDMARK FORUM.
2. WE/I AGREE TO COMPLY WITH THE ABOVE NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS, CONFIDENTIALITY
AGREEMENT, PROPRIETARY MATERIALS AGREEMENT AND INFORMED CONSENT ON HIS/HER BEHALF.
3. WE/I AGREE THAT OUR/MY SIGNATURE(S) ON A FAXED COPY OF THIS DOCUMENT SHALL BE DEEMED AN ORIGINAL.
Parent or Legal Guardian's Signature
Date
Parent or Legal Guardian's Signature
Date
SEXUAL HARASSMENT POLICY
Landmark Education 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 Education. If you believe you have been unlawfully harassed,
you should contact the local Centre Manager, or the Director of Human Resources at Landmark Education's World
Headquarters in San Francisco at +1 415-616-2401. If you have any questions about Landmark Education's Sexual
Harassment Policy or would like a copy of the Policy, please contact either of these people.
(c) 1991-2007 Landmark Education
www.landmarkeducation.com
510X-607

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