PEM Intensives 2 & 3 Intake Forms

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YOUR DETAILS

Name *

First

Last

Pronouns

Email *

Phone Number *

We will not use this for marketing purposes unless you give us explicit permission.

City *

SAFETY we Name

HEALTH & SAFETY

Emergency Contact's Name *

First

Last

Contact Number *

Relationship to You

I understand that PEM involves physical exertion and accessing genuine emotion, and I take part voluntarily and at my own risk. *

Any injuries, physical conditions, or limitations we should be aware of?

Any access needs or accommodations, or anything else we should know?

ABOUT YOU

Please fill in your details so we can get to know you before the workshop.

How Did You Hear About Us? *

Google/Search Engine
Word of Mouth
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Referral
Other

Please briefly detail what PEM classes you have taken so far. *

FINAL STEPS

Terms and Conditions | Privacy Policy

I have read and agree to the terms and conditions, and privacy policy. *

I agree not to teach PEM unless I am a Certified Instructor or have explicit written permission from PEM Acting. *

I confirm I am 18 years or older. *

(Optional) Media Opt-Out

I opt out of being photographed or recorded.

Select workshops may be photographed or recorded. These are rare opportunities to capture PEM in process. If you opt out, we will act in good faith not to film or photograph you wherever possible, and your image will not be published. Please refer to the Terms and Conditions for our full media policy.

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PEM Intensive Intake Form

YOUR DETAILS

HEALTH & SAFETY

ABOUT YOU

FINAL STEPS