Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

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Have you taken a class(es) with Samantha before? *

Yes

No

Medical Disclaimer *

Please be advised that this type of work is not for everyone. Immersion material can reveal challenging aspects about ourselves and may have a deep impact on your emotional, physical, and mental health and may bring up trauma memories and/or responses. This group experience is not intended to be a substitute for individual counseling or intensive psychological therapy. I am not a mental health practitioner and I do not have the expertise to perform as such. I do not provide medical or psychological advice, diagnosis or treatment. The opinions and teachings provided in the immersion are not intended to be substituted as medical or psychological advice, and should not be considered counseling, therapy or any form of medical or psychological treatment. In a workshop setting, I am to ensure the well-being of each participant. As part of my registration process, I collect medical disclosure information from each participant. This, along with all of the registration information, will be held in confidence. I kindly request that you disclose, with as much detail as possible, any relevant information concerning any known past or present physical, emotional, or mental health issue, injury or condition. I will review this information as part of the registration process. Please email me at samantha@afterbefore.live if you have any questions about your ability to participate in the event. If I have any questions I will contact you. In some circumstances I may request a participant provide written clearance from their medical doctor and / or mental health care practitioner authorizing participation in the series before acceptance. Please acknowledge that you have read and understand the medical disclaimer.

Acknowledged

Are you currently moving with any physical injuries? *

Yes

No

Do you have any mental or medical conditions that may be aggravated due to physical work or psychological stress? *

Yes

No

In the case of an emergency, I acknowledge that I am responsible for my own health care costs. *

Acknowledged

Please list your emergency contact *

First Name

Last Name

Please list their contact phone number *

Country

(###)

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Liability Release + Agreements *

I will not hold Samantha Lane, AFTER BEFORE PRODUCTIONS, or any other teacher, or assistants legally responsible for any injury, illness, accident, or other misfortune that may occur in connection with my participation during this event. I attest that all of the information I have provided is correct and true. I am responsible for my own personal safety and wellbeing during the event. I will not hold Samantha Lane legally responsible for any perceived act that is or may be detrimental to my person or health in whatever way.

Acknowledged

Cancellation Policy *

If you need to cancel for any reason after you have registered for this event, you will receive a 75% refund up to two weeks in advance of this offering (May 11, 2024). There will be no refunds within two weeks of our start date (excluding an emergency situation). I understand and acknowledge the cancellation policy.

Acknowledged

I acknowledge that all of the information I have provided is true *

Yes