Please Complete This FormYour information will not be sold, traded, or used by any outside organizations without your consent.Attending more than one workshop?Please complete one form for each workshopChoose a Workshop--- Select ---March 15, 2025: Principles and Practices of Aikido (BELLINGHAM)March 22, 2025: Principles and Practices of Aikido (GALIANO)April 13, 2025: Bringing Embodied Creativity Into a World of Chaos (INVITE ONLY)April 25 & 26, 2025: Becoming the Ground in a world of chaos (BELLINGHAM)May 2 & 3, 2025: Becoming the Ground in a world of chaos (SEATTLE)May 9 & 10, 2025: Becoming the Ground in a world of chaos (GALIANO)To register for more than one workshop, please complete one form for each.First and Last name *Phone Number *BirthdateEmail Address *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweEmergency Contact InfoEmergency Contact *PhoneEmail AddressRelationship to youWhat I hope to get out of this workshop *My biggest concern about attending this workshop *Other workshops I have attended that may share content with this one includeHow did you hear about this workshop?Pertinent medical history and underlying conditions that may affect participationRisk Release, Consent, & Assumption of Risk StatementPlease read the following carefully as it limits the liability of Educational Design Associates. *I hereby request to participate in a workshop, training, or retreat hosted by Educational Design Associates (hereafter referred to as EDA). In connection with this application, I hereby acknowledge and understand that: The purpose of this program is to offer movement and dialog-based learning activities to explore self-awareness, meaning-making, and consciousness development. This workshop will incorporate theatrical and martial arts strategies, potentially including standing, sitting, and horizontal activities, both alone and in physical contact with others. These activities will be aimed at building awareness and capacity. However, given that they may involve physical interaction between people, there is a potential for physical injury to myself as a participant. In choosing to take part in a program that involves movement, physical stretching, and partner practice, I acknowledge and accept the existence of a real risk of physical injury to my person. I understand the nature of these risks. Nevertheless, I voluntarily commit myself to undertake this opportunity and assume for myself the risks involved. I further acknowledge that this workshop delves into personal growth topics that may prove to activate or trigger things within my mental health or psychological development. I commit to taking responsibility for my own experience, including sitting out certain activities or even leaving the workshop, if necessary, in order to preserve my psychological wellbeing. I have read this Risk Release, Consent, & Assumption of Risk Statement and agree that it covers any and all program activities sponsored by EDA, its agents, employees, or instructors, whatever the location. I agree to indemnify and hold harmless Educational Design Associates, Daniel Kirkpatrick, any other paid or volunteer staff of EDA, partner organizations and their leaders, and the owners of the property in which this program takes place, for acts of commission or omission in the conduct of the program. I also agree to abide by the guidelines provided by EDA and to explicitly follow all instructions given. I acknowledge that my failure to do so could result in elimination from the program. I also acknowledge that all fees paid to the EDA are non-refundable and non-transferable.I have read and am OK with all the info in the provided packet.E-signature *DateRegister