Libido Ongoing Group Application

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Name: ______________________

Libido Ongoing Group Application

Redwood City, CA – 2009-2011

Space in the Libido Ongoing group is limited and participation is by application only. The following information will outline the procedure for applying for this ongoing group and by receipt of your application we will assume that you have read and agreed to the terms as explained here. Upon acceptance of your application, you will receive a participant contract for your signature to complete the registration process.

The cost of the Libido Ongoing group is $2350 for all 5 modules. A discount of 15% (total cost will be $1997.50) will be applied to all registrants paying in full by March 1, 2009. If you are 5Rhythms teacher, please contact Lori (lori@ecstaticproductions.com) directly for details about the teacher discount.
A deposit of $450 is required with this application. If you are accepted for this ongoing group, the $450 will be applied to the total cost of the workshop if paying in advance by March 1, 2009 or it will be applied to the cost of the last module if you are working out a payment plan with Ecstatic Productions. If you are not accepted for the ongoing group, you will promptly receive a refund of your deposit minus a $50 application fee.
Payment plans are available for this group. Each module must be paid for one module in advance. For example, module two must be paid for by the first day of module one, etc. The $450 deposit will only be applied to the last module and is therefore not considered as advanced payment for modules one through four.
The $450 deposit should be mailed to Ecstatic Productions at the same time you email your application and a digital photo of yourself to lori@ecstaticproductions.com. We will only review applications once the deposit has been received.
Please send your check or money order in US funds (we can not accept credit cards) to:
Ecstatic Productions

2050 Santa Cruz Ave,

Menlo Park, CA 94025 USA
If you have any questions or concerns about the application process or need additional information about the ongoing group itself, please contact Lori Smullin at 408.829.7366 or lori@ecstaticproductions.com.
Until we dance,
Lori
Please type your answers to the following questions in the boxes provided next to or below the questions. The boxes will expand to accommodate whatever amount of text it takes to answer the question.

Date of Application:		Photo
Name:
Address:
Business Phone:
Home Phone:
Mobile Phone:
Email:
Skype:
Current Occupation:
Date of Birth:
Male/Female:
List all your workshops and class experience in the 5Rhythms including the dates (month and year), name of the teacher and subject (e.g. Libido, Heartbeat, Waves….). If you are a 5Rhythms teacher, you need only put that in here.

Describe briefly any psychological work you have done, i.e. psychotherapy, counselling, group process:

Do you have any history of psychiatric treatment, including medication or hospitalizations? Are you currently on any medications?

Do you have any heath conditions we should know about?

What regular physical practices do you have, e.g. yoga, sports, etc.?

Describe a specific goal or intention you have in participating in this group?

Describe, in whatever way you wish (words, picture poem song, etc), what is your relationship with your sexuality these days? Of course this answer will change from day to day. For this, just take a moment to listen and see what answer is present as you apply for this intensive ongoing group.

Emergency Contact Information.
Please provide contact information for someone we can call for you in case of any severe physical or psychological emergency. Although an emergency is highly unlikely, this person should be someone you trust, who is able and willing to come to the location of the workshop to care for you and assist you home if necessary. Providing the name of an emergency contact is a requirement for attending this workshop and you are agreeing to allow us to contact this person if necessary at any time during the workshop,
In case of emergency please contact:

Name:
Their relationship to you:
Business Phone:
Home Phone:
Cell Phone:
Email: