Congratulations for choosing to advance your life with Family and Me!

1. This form is to be fill by the Teenage Participant and their Parent / Guardian.
2. This form will collect your information to register for the training.
3. Please allocate a minimum of 15 minutes to complete this form.
4. Page 2 is for your personal information and signature.
5. Page 3 and 4 are the Confidential Health Declaration to be filled in.
6. Page 5 are to be fill and sign by parent / guardian.
7. After you click "Submit", we will review your registration information and contact you regarding payment arrangements.

One of the results you can create for yourself in the Discovery Training is a greater awareness of how you operate in the areas of life which are significant for you. 

The questionnaire below will help you consider what are some of these areas which are important for you at this time. 

1. Please read this document thoroughly as it concerns your well-being and that of other participants in every training or programme offered by Heart Knocks Sdn Bhd (“Heart Knocks”). The words “training” and “programme” are used inter-changeably in this document.

Physical, mental and emotional health

2. All trainings and programmes offered by Heart Knocks are designed for participants who enjoy physical, mental and emotional health.

3. If you:

• suffer from any physical, mental or emotional ailment,
• have a medical or mental health professional attending to you, 
• intend or feel a need to consult a medical or mental health practitioner for any reason whatsoever, 
• are feeling unwell, depressed or have difficulty sleeping, or 
• feel uncertain whether the programme is suitable for you, 

you must consult with your medical and/or mental health professional and resolve your concerns and any physical, mental and emotional issue completely before participating in any programme. Heart Knocks will on request provide you and your medical or mental health professional with such information about the programme as may be reasonably required to enable you to consult your medical or mental health professional and to make an informed decision whether or not to participate in the programme.

Physical activity

4. The exercises in the programme will involve physical activity and you must be responsible to yourself and other participants to ensure at all times that you do not exceed your physical limitations

Mental and emotional experience

5. The programme is designed to bring out the best and to enhance personal effectiveness by tapping into the personal potential of each participant. This may involve giving participants the opportunity to reflect on and examine their own thoughts and emotions and to explore how they can shift them into new patterns of thought and emotion which will serve them in a better way.

6. The processes designed for such a personal way of learning can involve participants experiencing or re-experiencing suppressed or forgotten thoughts and emotions. It is natural for many participants to find themselves initially resisting such thoughts and emotions before allowing themselves to resolve and to re-integrate them in a healthy way.

7. Feelings of anger, sadness, anxiety, excitement, etc, may surface and abreactions such as crying and laughing may occur as part of the process of resolution and re-integration. Many people can identify similar experiences in the privacy of their own lives, outside of any training or programme.

8. Such experiences are a natural, albeit not an everyday, part of a physically, emotionally and psychologically healthy life.

9. However, if you have any concern over encountering such experiences for yourself or in other participants or you have any concern about being able to deal with such experiences, please discuss your concern with a Heart Knocks staff.

10. If at any time during the programme you feel uncomfortable to a degree that you think is excessive, please report it immediately to the trainer or to a Heart Knocks staff.

What the programme is NOT

11. The programme is NOT intended or designed to serve as:

• therapy
• counselling
• emotional support
• psychological support

12. The programme is NOT a substitute for professional help.

13. Neither the programme nor any trainer, facilitator or Heart Knocks staff is held out as being qualified to offer or as offering any advice, recommendation, treatment, therapy, remedy or other assistance with any physical, emotional or mental condition or issue.

Substance dependency

14. It is of fundamental importance that participants abstain from taking any alcohol or non-prescribed, mood-altering drugs, whether during or outside of the training sessions in the programme.

15. You should NOT participate in the programme if you are unable to refrain from taking alcohol or any non-prescribed, mood-altering drug as required by the programme.

16. Do NOT look to the programme as a solution or support for any dependency problem or issue.

Please answer ALL of the following questions completely, and follow the directions at the end of the form.

The information you provide will assist our trainers and staff to better support your participation. All your answers will be kept confidential.

If you are currently taking medication prescribed by your doctor, you will be asked to continue to take your medication as prescribed during the programme.

If Yes, we recommend that you consult with your doctor, therapist or counsellor, as the case may be, to resolve your complaint, symptom, condition or uneasy feelings, before participating in the programme.

Heart Knocks will provide whatever information about the programme which you or your doctor, therapist or counsellor, may require.

Please take responsibility for getting sufficient sleep throughout the programme.

If Yes, please ensure that you have 2 sets of inhalers or medication, one to be kept by you and the other, labelled with your name, to be kept available nearby or in the training room.

Click on "Submit" to complete.