Medical & Activity Agreement

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Select Event:* This field is required.
Real Coach 2025 Program
Real Woman 1 - August 2025 Workshop
Real Woman 2 - October 2025 Workshop
Real Man 1 - September 2025 Workshop
Real Man 2 - November 2025 Workshop
Real Spiritual Quest - December 2025 Workshop
Real Tantra Aphrodite & Eros - April 2025 Workshop
Real Relationships - June 2026 Seminar
Real Life Design - April 2026 Seminar
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I am :* This field is required.
Participant
Crew
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Please confirm you are still available to Crew on this event.* This field is required.
Yes, confirming available to Crew from 10am Wednesday to approx 10pm Sunday evening
No, no longer available
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We thank you for your willingness to contribute, and appreciate the time taken away from family and other commitments to support in this great cause.
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We confirm you are no longer available to Crew on this event, and thank you for your notification.

To submit this form, after completing Question 1 below, please go to the very bottom of this document, after the Full Standard Terms & Conditions, in order to select the submit button
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Name:* This field is required.
First Name
Last Name
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Your Email Address:
example@example.com
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Your Address* This field is required.
Street Address
Street Address Line 2
Suburb
State/Territory
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number * This field is required.
Area Code
Phone Number
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Profession* This field is required.
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Date of Birth* This field is required.
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Are you PregnantWomen attending Real Woman 1 or Real Woman 2 are not able to attend if they are pregnant.
YESNO
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Congratulations! Unfortunatly though you are unable to attend this workshop. Please call the Real Education office on 07 3348 5888 or email customerservice@realeducation.com.au to discuss transferring you to the next event.

Please disregard Enrolment Correspondence 2 of 2 that will appear on your screen once you hit submit.
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Please advise - if you currently hold a Working with Children Card (issued in Australian state or territory):* This field is required.
Yes, I hold a current Working with Children Card,
No, I do not hold a current Working with Children Card, but I expect I would be eligible to apply for one
No, I do not hold a current Working with Children Card, and I would not be eligible if I applied for one.
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Please advise - if you currently hold a Level 2 First Aide Certificate:* This field is required.
Yes, I hold a current Level 2 First Aide Certificate
No, I do not hold a current Level 2 First Aide Certificate
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Emergency (ICE) Contact Name* This field is required.
First & Last Name
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Emergency (ICE) Contact Phone Number/s* This field is required.
Aust +61
Mobile or Land Line Phone Number
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How is the person related to you?
IE: Dad, Wife, son, friend
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Have you been under the care with a Psychiatrist within the past 12 months?* This field is required.
Yes
No
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What is your condition and reason for seeing a Psychiatrist?
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I understand and agree* This field is required.
That given I have been diagnosed as being mentally ill, suffering from a mental illness, or a chemical imbalance, Real Education will have to assess my participation in this event. Part of this assessment will require that's by providing a Medical Clearance (on my Physician/Specialist's letterhead), and that the original signed Medical Clearance Letter will be provided to Real Education prior to my attendance being confirmed.
My Psychiatrist will provide in written form to Real Education with a Medical Clearance Certificate stating in their professional opinion I am emotionally, mentally and physically capable to attend this Real Education event.
If my attendance at the event is accepted I consent to my Medical Clearance Letter forming part of this Activity Agreement & Medical Form.
I confirm that given the nature of the event and the facilities at Real Education's chosen venue includes experiences that may involve intense emotional and/or physical release.
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.
I confirm that if my Psychiatrist consents to me attending the event that Real Education will not be liable nor will they be held accountable for any loss, injury or the like that I may suffer directly or indirectly as a result of attending and/or participating in the event.
Not Therapy: I acknowledge that the event is not therapy, nor is it meant to be a substitute for any form of health care.
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Name of Psychiatrist* This field is required.
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My Medical Clearance Certificate signed by my Psychiatrist is uploaded hereto
Drag and drop files here
Select files to upload
Your Doctors Medical Clearance Certificate is required in order for you to attend this Workshop. If the certificate is not available at the time of completing this document please arrange for the Certificate to be emailed to Real Education at customerservice@realeducation.com.au within 7 days from submitting this Agreement
Cancelof
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1. Do you consider yourself to have a substance addiction or psychological addiction?* This field is required.
Yes
No
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If yes, what specifically are you addicted to? [add additional information you think we might need to know]
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Do you have, or have you had, any of the following conditions or symptoms?
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Answer every question* This field is required.
Yes
No
1. Active Hepatitis
Row 0, Column 0
Row 0, Column 1
3. Hepatitis B
Row 1, Column 0
Row 1, Column 1
4. Hepatitis C
Row 2, Column 0
Row 2, Column 1
5. HIV
Row 3, Column 0
Row 3, Column 1
8. Medical Equip or Devices
Row 4, Column 0
Row 4, Column 1
9. Legally Blind
Row 5, Column 0
Row 5, Column 1
10. Physically Disabled
Row 6, Column 0
Row 6, Column 1
1. Active Hepatitis
3. Hepatitis B
4. Hepatitis C
5. HIV
8. Medical Equip or Devices
9. Legally Blind
10. Physically Disabled
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
1 of 7
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Did you answer yes to any of the above items?* This field is required.
Yes
No
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If you answered YES to any of the above questions, please explain* This field is required.
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Is there any other conditions we need to know about that is not listed above?* This field is required.
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1. Are you taking any medications?* This field is required.
Yes
No
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If yes please advise:
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2. Do you have any medical allergies ? (eg: Allergic to Penicillin)* This field is required.
Yes
No
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If yes please advise:
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3. Do you have any dietary allergies? (Eg: Celiac, Nut Allergy etc)* This field is required.
Yes
No
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Dietary Allergies detailed* This field is required.
Celiac
Dairy
Peanuts
Other
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Please describe the reaction* This field is required.
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4. Do you have any dietary preferences?* This field is required.
Yes
No
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Dietary Preferences detailed:* This field is required.
Celiac
Dairy Free
Vegetarian
Vegan
Other
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I authorise my relevant information being released to any medical personnel in the event I need urgent medical attention.(you must answer yes to be eligible to enrol into the event)
YESNO
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By signing below I confirm I have read, understand and agree to the terms and conditions set out in this document and I have truthfully answered all questions to the best of my knowledge.* This field is required.
Yes
No
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Signature* This field is required.Please use your mouse to sign your signature
Clear
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Date* This field is required.
Date
Day
Month
Year
Should be Empty: