Gateway Outreach Release and Registration Form

(to be completed by participant prior to attending workshop)

The Gateway Outreach Workshop remains an evolving training program of The Monroe Institute. The Outreach Trainer(s) retains the right to determine if I may or may not continue with the guided CD sessions and Program. If he or she deems me unsuited for continuation in a session or in the whole program, he or she will return the balance of my fee on a pro-rated basis.

In consideration of the mutual benefits which are expected to arise out of the activities in which I intend to engage which are designed by The Monroe Institute, and especially the benefits, educational and otherwise, which I myself expect to derive therefrom, I hereby release and forever discharge the Gateway Outreach Trainer(s), The Monroe Institute and all their officers, agents, representatives and employees, and their successors from all claims and demands whatsoever which I, my heirs, executors, administrators and assigns have, or may have, against them by reason of any injury of any nature whatsoever which I might suffer as a result of such activities, and I hereby expressly declare that any such activities are entered into by me voluntarily in an effort to increase my knowledge of the subjects under investigation.

I have read, understand, and agree to the above.

Name: ___________________________________

Name you like to be called ___________________

Address __________________________________

City _______________________ State _________

Country __________________________________

Postal or Zip Code __________________________

This course: _______________________________

Course date: ______________________________

Trainer: __________________________________

Location: _________________________________

Date of Birth: ____________________

Home Phone: ____________________

Work Phone: _____________________

E-mail __________________________

Fax: ____________________________