VELOCITY LEADERSHIP Detailed Student Information Form

CONGRATULATIONS on your choice to continue your journey of personal development and success with Part Three: The Velocity Leadership Program!

The following form is required to be completed for participation in Velocity Leadership. All information will be held in the strictest of confidence. If you have any questions or require assistance completing this form, please do not hesitate to contact our office at (310) 571-8045 or via email at support@lifedesigneducation.com.

Full Name*

First NameLast Name

Preferred Phone Number*

Email

example@example.com

Approximately what year did you complete the Freedom Course (aka Part One, The Basic)?*

Approximately what year did you complete Life Design (Part Two, Advanced)?*

Who are you? (Your Stand)*

Has your address changed since your Life Design?*

NoYes

Please list any allergies (food, medication, etc.):*

Briefly describe any food preferences or dietary needs (i.e Vegan, Kosher, etc.):*

Briefly describe some of the challenges that might come up for you in Velocity Leadership:*

HEALTH INFORMATION

In the Life Design Education trainings, you will be invited to examine your life and various issues regarding your life. You should be aware that if any of the issues have sadness or difficult feelings and emotions attached to them in the normal course of your life, it is likely that these same feelings and emotions will emerge in the Life Design Education courses. You must decide whether this is something you can handle at this time. Your willingness to experience these feelings and emotions honestly, and then let go of them, can open the way to a more joyful experience of living. The choice to do so, however, and the degree of your participation in the process, rests with you alone.

The information requested here is meant to enable Life Design Education to better support you during the course. It is not possible for Life Design Education to predict any student’s experience. If during the course you find yourself feeling uncomfortable or need assistance, notify the staff immediately.

REQUIREMENTS FOR PARTICIPATING

If you have any physical problems that may make it difficult for you to participate in the Life Design Education courses, it is recommended that you discuss this with your physician to determine the appropriateness of your participation. You MUST consult with a professional counselor, therapist, or physician and obtain a signed statement that there are no therapeutic contradictions to your participating in the Life Design Education courses if any of the following conditions apply:

You have been hospitalized for a psychiatric or psychological disorder within the last five years.
You are currently in counseling or therapy for substance abuse, PTSD, abuse or trauma, major depression or anxiety disorders, or similar diagnoses.
You have been prescribed within the last six months or are currently taking any major tranquilizer or antidepressant medication such as Lithium, Thorazine, Stelazine, or Haldol.

If any of these conditions apply to you, you must request a copy of this online form and a copy of the "Notice to Professional Counselor" letter from Life Design Education. This online form and letter must be presented to your therapist or prescribing physician to have him/her/they read the form and the "Notice to Professional Counselor" letter in its entirety and discuss the advisability of your participation. If he/she/they agree there are no therapeutic contradictions, have the letter be signed and dated by all parties.

Please be aware that this information is NOT intended to be used by Life Design Education for the purposes of screening. Life Design Education programs are experiential educational programs; they are neither psychotherapy nor medical therapy. Life Design Education does not and cannot screen its students. Only you can decide what is right for you, and the information provided here is to assist you with that decision.

Please list any medical issues that the course facilitators and staff should be aware of. This includes both physical and emotional/mental health issues, conditions, treatments, therapies, and medications you are currently receiving (please be specific.)*

If not applicable, type N/A

Have you ever been hospitalized for psychiatric care or mental disorder? If so, please describe what for and when.*

If not applicable, type N/A

EMERGENCY CONTACT INFORMATION

Please provide the name, relationship, and phone number of an emergency contact who Life Design Education facilitators may contact during the training in case of of an emergency.

EMERGENCY CONTACT*

First NameLast Name

Relationship *

(Mother, Husband, Daughter, Neighbor, Co-Worker, etc.)

Phone Number*

By signing below, you hereby acknowledge and attest that you have thoroughly and carefully read the information contained herein, that you understand it and agree to it, that you have answered all questions truthfully, and that you have fulfilled the requirements for participation in the Velocity Leadership Program.*

First NameLast Name

Signature*

Connections Course - Part Three: The Velocity Leadership Program