Medical History & Activity Form

Real Education

Confidential
Activity Participation Agreement & Medical History Form

Please carefully read & complete this form to confirm your attendance.
Completing this Form, reading and agreeing to the Terms of this Agreement is a pre-condition of your attendance into the event nominated below.

Please note, to complete this document you will be required to provide details such as your Doctors phone number, your Medicare Number and Health Insurance Policy details. We suggest you have this information on hand at the time of completing this Form, as an incomplete form may result in de-enrolment into the event nominated below, and you may not be eligable for any refund of monies paid.

In the event changes to this Activity Participation Agreement & Medical History Form need to be made after submitting, please ensure you email Real Education at customerservice@realeducation.com.au and provide a full detailed list of all relevant information relating to your health and wellbeing to ensure you still remain eligable to attend the Workshop/Seminar/Program.

Specific Workshop/Seminar Information
I am : *

Participant Re-Sit Participant (I've participated in the event previously) Crew
Select event : *

Real Woman 1 Real Man 1 Real Woman 2 Real Man 2 Real 3 Sacred Circle Real Life Design Coach Program Real Relationships Real Teens
Please confirm you are still available to Crew on this event. *

Yes, confirming available No, no longer available
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.
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
1. General Information
Your Name *
First & Last Name
Have you already completed an Activity Agreement & Medical History From for an event this Calendar Year? Calendar Year meaning have you submitted this form previously sometime since January this year *

Yes No
To assist Crew and Participants in reducing administration time submission of one full Activity Agreement and Medical History Form once a year - only on the basis that you confirm every other event for that year that the details on the first Activity Agreement and Medical History Form submitted for that year are unchanged.

It will be your responsibility to advise Real Education of any and all changes immediatly. If you choose to submit only one full Activity Agreement & Medical History Form once a year then you confirm when completing any subsequent Medical History & Activity Agreements that the information provided in the first document is still current, true and correct and that agree, if you omit to notify Real Education of any and all changes to the information contained in your first document, Real Education will not be held responsible for any detrimental impact or effect this may have or create as a result.

If this is your subsequent Activity Agreement and Medical History Form for the current year, please read over your first/initial Activity Agreement and Medical History Form before answering the following questions, and to ensure those answers are still current, true and correct.
For what event THIS CURRENT CALENDAR YEAR did you submit your first Activity Agreement & Medical History Form for? *
EG: TYPE the Event Name Ie: Real Woman TYPE the Month ie: March TYPE the year: ie Must be this current Calendar Year
I confirm that the information contained in my first Activity Agreement & Medical History Form provided THE SAME CURRENT Calendar year as the Event Attending is still current, true & correct and confirm it is my responsibility to notify Real Education of any changes when they occur. *

Yes, I confirm No, I do not confirm
You have selected "NO I do not confirm". You will be required to complete the full Activity Agreement and Medical History Form.
Are you under 18years of age? *

No Yes
Important information for Participants/Crew Under 18 years of age *

Before the commencement of the program any Participant or Crew under the age of 18 years old must hand to Crew In Charge all prescribed medication (except asthma puffers). Such medication must be in the original labeled pharmacy packet with directions and be accompanied by written instructions on dosage and times to be taken. Any Participant / Crew Member under the Age of 18 must be accompanied by their Parent/Guardian, and is the responsibility of the Parent/Guardian during the entire course of the event. The Parent/Guardian must sign this Activity Participation & Medical History Form on behalf of the Minor
Date of Birth *
Parent/Guardian Name of Minor *
Parent/Guardian Full Name
Full Name of Minors' appointed Guardian during the Workshop *
Full name of Guardian during Workshop
Your E-mail *
Your Address *

Street Address

Street Address Line 2

City State/Territory

Post Code
Profession *
Phone Number *

Area Code Phone Number
Please tick relevant boxes: *

I hold a current Working with Children Blue Card, I don't hold a current Working with Children Blue Card, but I expect I would be eligible to apply for one
Please advise - if you currently hold a Level 2 First Aide Certificate: *

Yes, I hold a current Level 2 First Aide Certificate No, I do not hold a current Level 2 First Aide Certificate
Do you agree to complete a Covid19 Wellbeing Screening prior to attending the event? This is NOT a Medical Covid19 TEST - it is screening the Participants by asking the standard "Are you Well, Have you been in a Lockdown area" in the last 14 days Questions, AND taking your temperature *

Yes I consent to Covid19 Wellbeing screening IE Questions & Temp Check No I do not consent
If you answer NO, or if you arrive and are:
1. unwell or have Covid19 symptoms
2. have been tested positive to Covid19
3. have been in a Covid19 hotspot within 14 days prior to the event commencing

you will be unable to attend the event and Participants will be transferred to the next event.

If you answer YES you agree to complete a Covid19 Wellbeing Screening no sooner than the day before the event commences. And you further consent to having your temperature taken at registration on your arrival to the event.
2. Emergency Contact

"ICE" In Case of an Emergency
I confirm that my Emergency Contact details remain unchanged from my previous Activity & Medical History Agreement Form previously submitted earlier this year.
Emergency (ICE) Contact Name *
First & Last Name
Emergency (ICE) Contact Phone Number/s *

Aust +61 Mobile or Land Line Phone Number
Relationship to you *

Partner Friend Father Mother Son Daughter Father-in-Law Mother-in-Law Daughter-in-Law Son-in-Law Employee Employer Work Colleague
Doctors Name *

Dr. Name Clinic Name/Location
Phone Number *

+61 Phone Number
Medicare Number *
Do you have Private Health Insurance? *

Yes No
Insurance Provider *
Policy Number *
Insurance Fund's Contact Phone Number *

Area Code Phone Number
3. Psychosocial History
I confirm that my Psychosocial History details remain unchanged from my previous Activity & Medical History Agreement Form previously submitted earlier this year.
Have you been under the care with a Physician/Specialist, Psychiatrist, Psychologist or other within the past two years? NOT Health Coach - under the care of a Government Approved Mental Health Physician/Specialist *

Yes No
Are you currently in counselling / treatment? *

Yes No
If yes, please describe briefly *
Reason for counselling (check all appropriate responses) *

Academic Divorce Suicide Family Issues Substance Abuse Depression Career
If other, please elaborate *
Have you ever been diagnosed 1. As mentally ill / having a mental illness? (Eg: Schizophrenia, Depression/Anxiety, Personality Disorder, Eating Disorder etc) or 2. Psychologically unstable due to chemical imbalance? (Eg: Bipolar Disorder) **If unsure please seek your Doctors confirmation *

Have NOT been diagnosed with a Mental Illness or Chemical Imbalance Depression/Anxiety Schizophrenia Personality Disorder Eating Disorder Bipolar Disorder
I understand and agree *

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 my Physician/Specialist to declare in their professional opinion that I am emotionally, mentally and physically capable to attend this Real Education event 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. If my attendance at the event is accepted I consent to my Medical Clearance Letter forming part of this Activity Agreement & Medical Form, and being provided to the necessary Real Crew or Medical Crew as required. I confirm that given the nature of the event and the facilities at Real's chosen venue includes experiences that may involve intense emotional and/or physical release. Real Education holds the right to cancel my enrolment and refund to me, less a cancellation fee of up to $995 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 Physician/Specialist 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.
I confirm, *

I have contacted my Physician/Specialist and confirm they will provide 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. Failure to provide this Clearance Certificate will result in my inablity to attend the Real Education event. I understand that Real Education events are not therapy, nor are they meant to be a substitute for psychotherapy or any other form of health care.
Name of Physician / Specialist *
My Medical Clearance Certificate signed by my Physician/Specialist is uploaded hereto
4. Medical History
I confirm that my Medical History details remain unchanged from my previous Activity & Medical History Agreement Form previously submitted earlier this year.

3. In the last year, have you ever drunk or used drugs more that you meant to? *

Yes No
Please note additional information you think we might need to know:
4. Have you felt you wanted or needed to cut down on your drinking or drug use in the last year? *

Yes No
Please note additional information you think we might need to know:
5. Do you consider yourself to have a drug or alcohol addiction? *

Yes No
If yes, what specifically are you addicted to? [add additional information you think we might need to know]
Do you have, or have you had, any of the following conditions or symptoms?

NOTE: Further to your terms and conditions of your attendance, if you are legally blind or have a physical disability, we will have to assess your participation in this Workshop. We will require further information and or possibly medical clearance, given the nature of the Workshop and the facilities at our chosen venue. We hold the right to cancel enrolments and give full refunds if the venue and facilities are not suitable for your specific needs.
Did you answer yes to any of the above items? *

Yes No
Have you ever been hospitalised for any of the above conditions? *

Yes No
If you answered YES to the above 2 questions, please explain further in section 5. below, titled ‘Medical History Detailed Responses’.
5. Medical History Detailed Responses
If you answered YES to any of the Medical History questions above, please explain below. Include the following:

*   What specific symptoms are occurring *   How you care for symptoms/conditions

         *   How often symptoms/conditions occur *   How symptoms/conditions restrict your activity

         *   How long symptoms/conditions last *   Date of last occurrence
Please advise No/s Ticked Yes - and provide specific details
6. Medications, Allergies & Diet
I confirm that my Medical details regarding Medication & Dietary requirments remain unchanged from my previous Activity & Medical History Agreement Form previously submitted earlier this year.
Due to legal constraints Real Education crew are not permitted to administer analgesics (Panadol, Asprin etc). A letter from the participant’s doctor stating that there is no allergy may assist in the case of an emergency.
1. Are you taking ANY medications (prescription or non prescription), or suffer from any Medical condition? (eg: Suffer from Asthma / Type 1 Diabetic) *

Yes No

2. Do you have any MEDICAL allergies ? (eg: Allergic to Penicillin) *

Yes No

3. Do you have any DIETARY ALLERGIES? (Eg: Celiac, Nut Allergy etc) *

Yes No
DIETARY ALLERGIES detailed (Allergy - NOT lifestyle choice) *

Celiac Dairy Free Vegetarian Vegan Pescetarians
Please detail all known allergic REACTIONS & where applicable all Medical / Medication required in case of reaction *
Example - In event of celiac contamination I may suffer migraines, seizures, loss of ability to speak, constipation and/or .....
3. Do you have any DIETARY PREFERENCES? (Lifestyle Choice) *

Yes No
LIFESTYLE DIETARY detailed (Lifestyle choice - NOT Allergeric) *

Celiac Dairy Free Vegetarian Vegan Pescetarians
I confirm

Real Education will endeavour to cater to meet my dietary allergy needs, where the dietary needs are "standard" IE: Gluten Free, Dairy Free, Vegetarian and/or Vegan, only if advised in writing a minimum of 14 days before the event. Both Full Cream Milk and Almond Milk will be provided for Tea/Coffee. Any meals with dairy based creams will be Coconut Milk. If my dietary combination needs is simply a life-style choice my dietary needs may not be able to be accommodated. I will cater to meet my own dietary needs outside of these alternatives. In the event this form is provided after the due date the additional cost to meet any approved dietary needs from the Chef will be passed onto the enrollment fee.
7. Declaration
I, *

understand that the completing and returning this document by myself to Real Education creates a legal and binding agreement to all Terms and Conditions contained herein. confirm I will not solicit business from any Participant, Crew, Guest or past Graduate at any time before the Activity, during, and even at any time once the event has completed. This includes but is not limited too indirect solicitation on Social Media or at non Real Education organised social or other events. understand that should I choose to leave an Activity before completing the Activities then the fees paid are non-refundable. confirm the information provided is a complete and accurate statement of the physical and psychological factors that may affect my participation in this Real Education Event. I realise that failure to disclose such information could result in serious harm to myself and to fellow participants. acknowledge that the event is not therapy, nor is it meant to be a substitute for psychotherapy or any other form of health care. NB: Where I am currently under the care of a physician or therapist, I have already consulted with my physician/therapist about the advisability of my participation. Where I am currently, or have recently been under treatment for any physical or psychological issues, I will discuss this with the Office Administration staff so that we are better able to support you during the event. agree that Real Education is responsible only for the orderly presentation of the Activities and that I am responsible for my own participation in the Activities and my own well-being. confirm that I am not suffering from mental illness nor am I psychologically unstable unless where otherwise stated and where a Medical Clearance Certificate is required to be, and is to be provided from my Specialist prior to the event commencing. agree that I will remain free from, and not be under the influence of any alcohol, drugs or conscious altering substances (with the exception of prescription medication) for the duration of the workshop - including upon arrival to the Activity at registration. agree to notify Real Education Accelerated Learning should there be any changes in my health status. I authorise Real Education Accelerated Learning to release this information to medical personnel in the event of an emergency. I also authorise Real Education Accelerated Learning to contact my physician or therapist to clarify any questions about my health or wellbeing. I understand that Real Education Accelerated Learning reserves the right to refuse participation to any person for medical reasons. understand that it is a condition of my participation in this Real Education event to take responsibility for my own personal welfare, wellbeing, health and safety, including responsibility for administering any medication and managing any allergies I may have. agree to release, absolve, indemnify and hold the Providers, its servants and agents, harmless from and against all and any actions or claims which may be made by you or on your behalf or by other parties for or in respect of or arising out of any injury, loss, damage or death caused to you or your property whether by negligence, breach of contract or in any way whatsoever including participating in the Activities or driving, or arising out of, any activity carried on by the indemnified. consent to be present at the Premises voluntarily in the full knowledge that in doing so I assume full risk of any injury that I may suffer from any source, including but without limiting, the actions of the Providers by holding sufficient and relevant Insurance Cover that includes Life cover, Total and Permanent Disability, Income Protection and Trauma. agree to observe and follow the Instructors directions or instructions or supervision at all times. Where I fail to follow such directions or instructions or supervision and wilfully or negligently does or omits to do something that causes damage to myself, to any other person or property, the car(s), the premises, or the facilities, then the I indemnifies Real Education and the Providers for all actions or claims arising from my wilful or negligent actions.10.2 The Mentor Coach / Participant / Crew Member / Reviewer / Guest acknowledges that it is important to their own and other’s safety for them to observe and follow instructions and directions at all times and acknowledges that if they fail to do so, the Providers have the right to ask them to leave the premises or facilities, and to cease participating in the Activities. acknowledge that the Activities may from time to time be filmed, audio recorded and photographed. I understand and agree that the video footage, audio recordings and photographic images taken at the Activities is for free unrestricted use by Real Education and its agents in editorial, advertising, educational and promotional material. I understand that international copyright and intellectual property rights on these images will remain the property of Real Education who will be entitled to broadcast, publish or otherwise distribute these materials and any product thereof in anyway or matter that they see fit in perpetuity. By consenting and agreeing to the terms and conditions of this Agreement I agrees I have no further claims for compensation from Real Education or its agents. In cases where an individual is filmed, audio recorded or photographed, additional consent will be revisited in accordance with this Clause. I acknowledge that the Providers have the authority to refuse entry, terminate or cancel the Agreement and Activities at any stage due to weather conditions, force majeure, my or anyone elses health, conduct, behaviour or attitude, or damage to the facilities, premise or vehicles. understand that my participating in the Activities in whatever role or capacity in any Real Education Event does not qualify me to teach the Activities and I agree NOT to attempt to reproduce any or all of the Activities I participate in or witness in an Real Education Event.

Please read below for full Standard Terms & Conditions *In order to SUBMIT this FORM you must Agree to the T&C's, electronically Sign.
This Agreement covers all events that you as an individual participating in any capacity or role before, during or after the Activity.

1. Term of this Agreement

This Agreement remains in place and applies in every instance where the Mentor Coach / Participant / Crew Member / Reviewer / Guest participates in the Activities.

2. Rights of a Consumer

This Agreement does not purport to or have the effect of excluding, restricting or modifying the application of any of the provisions of the Fair Trading Act or the Trade Practices Act 1974 (Cth) or the exercise of a right of conferred by any such provision or any liability for a breach of condition or warranty implied by such provision.

3. Governing Law and Jurisdiction

This Agreement is governed by the laws of Queensland. In relation to it and related non-contractual matters each party irrevocably submits to the non-exclusive jurisdiction of courts with jurisdiction there, and waives any right to object to the venue on any ground.

4. Agree that this Release, Waiver of Liability and Indemnity is intended to be as broad and inclusive as is permitted by the laws of Queensland and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.I also acknowledge that I have read this Release, Waiver of Liability, and Indemnity, fully understand its terms, understand that I am assuming full risk of participating in the Activities and using the facilities and has signed this Agreement freely and voluntarily without any inducement, assurance or guarantee being made and intends their signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

5. Entire Agreement

This Agreement constitutes the entire agreement between the parties and shall supersede all other negotiations, representations, proposals and agreement whether oral or written with respect to the subject matter of this Agreement.

6. Privacy Statement

6.1 This Privacy Statement sets out the Providers obtains, uses and discloses information about you. We are bound by the National Privacy Principles set out in Schedule 3 of the Privacy Amendment (Private Sector) Act 2000 ("the Act"). We are committed to providing a high level of privacy in relation to all Personal Information that is collected by us. You consent to the privacy statement by signing this Agreement.

Personal Information is information about your health, your contact details, and your bank account details. The types of Personal Information generally collected by us include your name, address, mobile and telephone numbers, facsimile number and e-mail address, payment details, whether you are on any medication and other health related information that is necessary to properly advise you about fitness training. Personal Information is also collected when you provide business cards or other documentation to us containing such Personal Information. Personal Information also includes information we collect in the course of providing services to you and communications between you and us.

6.2 Any Personal Information that we collect about you will be used and disclosed by us so that we can provide you with the best training program to suit your needs. For example, we must make all of our instructors aware of information about your health, so that they can safely advise about training programs. If we were to sell our business, we may disclose your Personal Information to the purchaser of the business.

6.3 We will add your name, address, mobile and telephone numbers, facsimile number and e-mail address to our database which may be used for marketing purposes such as providing to you new offers in relation to Activities. If we retain your Personal Information, you have our commitment to your privacy.

6.4 We do not and will not rent, sell or otherwise disclose your Personal Information to any other company or organization, without your prior consent where that consent is required by law.

6.5 Subject to what is permitted by law, the types of third parties we may disclose your personal information to include, where relevant:

credit reporting agencies;
our agents, contractors and external advisers whom we engage from time to time to carry out, or advise on, our functions and activities;
your agents and contractors, including your finance broker, builder and settlement agent and your legal or financial adviser;
your executor, administrator, trustee, guardian or attorney;
our referees;
regulatory bodies, government agencies, law enforcement bodies and courts;
any person or organisation who introduces you to us;
other organisations with whom we have alliances or arrangements for the purpose of promoting our respective products and services;
any agents used by us and our business partners in administering such an arrangement or alliance;
debt collecting agencies;
other financial institutions;
external payment systems operators;
your and our insurers or prospective insurers and their underwriters;
any person to the extent necessary, in our view in order to carry out any instruction you give to them by us;
other organisations (including our related bodies corporate) and their agents for the marketing of specific products and services (unless you tell us not to.)
16.6 We use all reasonable endeavours to secure your Personal Information and to keep this information accurate and up-to-date.

7. Statement of Understanding

I represent that I am participating in the Activities voluntarily and not as a result of coercion, pressure, and or condition of employment or to satisfy anyone other than myself.

I warrant that all relevant health information has been disclosed to the Provider.

I understand the Activities are not therapy, nor is it meant to be a substitute for psychotherapy, counselling or any other form of health care.

I have read, or have had read to me the above terms and conditions and having understood the same, I consent and agree to undertake Real Education Activities on the above terms and conditions of this Agreement.

OR

I warrant that I am the legal parent or guardian of the Mentor Coach / Participant / Crew Member / Reviewer / Guest and that I give him/her permission to participate in the Activities. I have read and understood these terms and conditions and warrant that all of the information that has been provided the Mentor Coach / Participant / Crew Member / Reviewer / Guest is true and correct, and that all relevant health information about the Mentor Coach / Participant / Crew Member / Reviewer / Guest has been disclosed to the Providers. I understand that I am fully responsible for the Mentor Coach / Participant / Crew Member / Reviewer / Guest actions whilst undertaking the Activities and that these terms and conditions apply to me as if I was the Mentor Coach / Participant / Crew Member / Reviewer / Guest myself.

8. All Real Education current and future events

6.1 Act of God Disclaimer In the event of a natural disaster or “act of god” such as but not limited to, Earthquake, Explosions, Fire, Thunderbolts, Storm and Flood, Real Education Accelerated Learning is not liable for including but not limited to injury, damage or loss of property, Workshop/Seminar/Program fees, all travel cost such as airfares and transfers and all accommodation costs.

At the sole discretion of Real Education Accelerated Learning we may elect to reschedule the event, but are under no obligation to do so.
Have you read the Workshop/Seminar/Program R.E.A.L. Crew Criteria for Selection and Continued Participant document? *

Yes No
I have read, understand and agree to the terms and conditions set out in this document and to the terms and conditions of the Workshop/Seminar/Program R.E.A.L. Crew Criteria for selection and continued participation and further agree to be bound by the Participant Terms and conditions detailed in my original Participant Manual, and the current Participant Manual. Further, I have truthfully answered all questions to the best of my knowledge, and by signing below I confirm I will abide by all terms and conditions set out in these documents. *

Yes No
I have read, understand and agree to the terms and conditions set out in this document and further agree to be bound by the Participant Terms and conditions detailed in the Participant Manual which I will be supplied to me at the beginning of the Workshop. Further, I have truthfully answered all questions in this document to the best of my knowledge, and by signing below I confirm I will abide by all terms and conditions set out in this document and the terms and conditions set out in the Participant Manual. *

Yes No
Parental/Guardian permission is given for the Participant under the Age of 18 years of age to attend the nominated Workshop/Seminar/Program by the Parent/Guardian signing below
Signature *

Clear
Date *

Month Day Year
Should be Empty:

	Yes	No
Do you smoke?
Do you use drugs?
Do you drink alcohol?

	Daily	Weekly	Monthly	In the last 6 months	Over 6 months ago	Never
Alcohol
Tobacco
Recreational Drugs

	Yes	No
1 Active Hepatitis
2 Arthritis
3 Asthma
4 Bleeding Disorder
5 Blood Disorder/Anemia
6 Broken Bones
7 Cancer
8 Chest Pain or Pressure
9 Chronic Cough
10 Circulation Problems
11 Diabetes
12 Difficulty Urinating
13 Eating Disorder
14 Emotional Problems
15 Endocrine/Gland Problems
16 Frequent Dizziness
17 Frequent Fainting
18 Frequent Lung Infections
19 Headaches
20 Heart Attack
21 Heart Disease (Of Any Kind)
22 Heart Murmur
23 Heart Palpitations
24 High Blood Pressure
25 Heartburn
26 Hep B or C

	Yes	No
27 HIV OR AIDS
28 Hypoglycemia
29 Intestinal Problems
30 Irregular Heartbeat
31 Joint Problems
32 Kidney Problems
33 Learning Disorder
34 Medical Equip Or Devices
35 Neck Or Back Problems
36 Obesity
37 Psychiatric Problems
38 Seizure Disorder
39 Seizure (Within Last Year)
40 Shortness Of Breath
41 Sickle Cell Trait/Disease
42 Significant Head Injury
43 Skin Problems
44 Thyroid Problems
45 Tuberculosis (TB)
46 Ulcer
47 Unexplained Sweating
48 Unexplained Weight Loss
49 Vision Impairment

	Medication	Condition	Dosage	Current side effects
1.
2
3
4

	Medication	Reaction
1
2
3
4

Real Education

Activity Participation Agreement & Medical History Form

1. General Information

2. Emergency Contact

3. Psychosocial History

4. Medical History

5. Medical History Detailed Responses

6. Medications, Allergies & Diet

7. Declaration