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LayoutCongratulations on having registered in The Landmark Forum. The Landmark Forum is an enquiry 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.
• PARTICIPANTS 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 LandmarkForum and beyond. This information will be held in strictest confidence. All questions must be answered in full before yourchild can participate in The 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. Return the completed form in the enclosed envelope within one week of receipt.
1. The Landmark Forum (City) Month Dates Year 2. Name (Last) (First) (Name I like to be called) 5. Age (as of Day 1 of the Course) Date of Birth (Day/Month/Year) 6. Have you (young person or teen) completed The Landmark Forum? 7. Please list the names and ages of siblings, relatives, or friends who are also registered in this course with you.
8. Please list the names and ages of siblings who are NOT registered in this course with you.
9. If the participant has a mentor, please complete the following information: Mentor’s name. Home Phone ( ) Work Phone ( ) Other Phone ( ) Parent Information:
10. Parent Name ÅMother ÅFather ÅLegal Guardian (Last) (First) 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” Home Phone ( ) Work Phone ( ) Mobile or Other Phone ( ) Spouse/partner’s name Has spouse/partner completed The Landmark Forum? 11. Parent Name ÅMother ÅFather ÅLegal Guardian (Last) (First) 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” Home Phone ( ) Work Phone ( ) Mobile or Other Phone ( ) Spouse/partner’s name Has spouse/partner completed The Landmark Forum? 12. What physical conditions does your child have that we should know about? No Special Condition (Physically Challenged, If yes, please specify Wheelchair, Hearing or Vision Impaired, IMPORTANT NOTE: We provide only one menu. If the participant has a special diet or has special food requirements of any nature, they will need to provide their own lunch. We are not able to provide refrigeration or preparation of any kind. The Registration Fulfilment 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.
c. 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. Emergency Information: In case of an emergency in which your child incurs a serious injury or illness, the procedure
1) We will call emergency medical services.
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 is to be filled out by the person who will be doing the course and should be written in their own handwriting.
The Landmark Forum is about what is possible and having a life you love. To get the most out of being in the course, we ask that you say what you would like to accomplish in your life that is important to you. There may be problems or concerns that you are struggling with, and you may include those as well.
You might consider some of the following: • relationships with the people in your life: • what you want to make a difference with • what is important and what matters to you What I intend to accomplish in The Landmark Forum is:
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 ofthis 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 whoadvise Landmark Worldwide (“Landmark”).
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 havea full understanding of each and every paragraph which follows and that you understand our recommendations and will complywith 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
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 experienceand short exercises, the Programme 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 Programme, people come to grips with what it means tobe human — not as a mere classroom exercise, but as a rigorous enquiry. The Programme offers a unique technology throughwhich 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 WORLDWIDE (“OUR ADVISORS”) STRONGLY RECOMMEND THAT YOU DO NOT
PARTICIPATE in the Programme.
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 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 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 hospitalised; (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 Programme; or (f) are uncertain about your physical, mental or emotional ability to participate in the Programme.
NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS (continued)
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 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. 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 Programme 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 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 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 Fulfilment Manager at the Centre delivering this Programme who will provide you with such information.
The following Agreements are intended to have legal significance. If you have any questions
about their meaning, please feel free to consult a solicitor.
PARENT RELEASE STATEMENT
The purpose of this statement is to ensure the safety of participants. We recommend that parents themselves bring and pick up a. THE LANDMARK FORUM FOR YOUNG PEOPLE: I will be bringing and picking up
my young person for all sessions of the Programme.
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 Programme: ____________________________________________________ ___________________________________________________ ____________________________________________________ ___________________________________________________ A parent, legal guardian, or legal designate must sign-in with the young person each morning. A young person WILL NOT be released at the end of the day until an authorised person has signed a card for their release.
c. 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 maximise their participation in The Landmark Forum. Landmark staff and the people who assist will not manage whether your teen stays or leaves the premises. 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 representative of Landmark Worldwide (“Landmark”) 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 Agreements (continued)
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 (b) I am using or have used psychotropic or mood altering drugs which are listed in the Notice of Important Information and (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.
(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; and (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 is responsible solely for the orderly presentation of 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 emotional discomfort, I agree to notify the Manager of the Landmark Centre which delivered the Programme. 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.
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 to approve my participation in the Programme. 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 Centre Manager, or the Director of Human Resources at Landmark ’s World Headquarters in San Francisco at +1-415-616-2401. If you have any questions about Landmark’s Harassment Policy or would like a copy of the Policy, please contact either of these people.
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 legalrights are not shared, the appropriate parent or legal guardian should complete the lower portion of this form. Please call theCentre 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, AND INFORMED CONSENT, ON MY CHILD’S
I agree that my signature on a faxed copy of this document shall be deemed an original.
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.
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, 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.
Please print Parent/Legal Guardian’s name here: PARTICIPANT
I understand that The Landmark Forum is a private and personal experience for each person who participates. I agree to respectthe privacy of all participants and the things they say and do, and I agree to keep all such information private and confidential. Ihave been informed that in order for me to receive the results of the Programme, my participation must be an expression of myown free choice. I represent that I am participating in the Programme voluntarily and not as a result of coercion, pressure, or tosatisfy anyone other than myself. I AGREE TO ABIDE BY THE ABOVE NOTICE OF IMPORTANT INFORMATION AND HEALTH WARNINGS,
PARENT RELEASE STATEMENT, 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.
2005–2013 Landmark Worldwide www.landmarkworldwide.com
This information sheet is a short guide to tacrolimus ointment (also known as Protopic). Itcontains information, which will help in understanding what tacrolimus ointment does, how it works,how it is used and what the possible side effects might be. Tacrolimus ointment is an ointment applied to the skin. It is not a steroid. Tacrolimus ointment is animmunomodulatory drug, which means it mod