I P S A
Personal Enrichment Program
Info@SurrogateTherapy.org   
3428 Motor Avenue, Los Angeles, CA  90034   
Phone: (1) 310.836.1662         
Personal Enrichment Program -- Application

Date
Your Name
Email address:
Postal Address:
CityStateZip
Day Phone  (        )                      Evening Phone (        )

Birth date Sexual Orientation
Current Occupation
Any special needs:
Dates and time you are available to participate:
Dates available:


Using additional pages, please write a several page letter that answers the following questions:
1) Why do you want to participate in the Personal Enrichment Program (PEP)?
2) What are your goals and concerns regarding participation in PEP?
3) What did you begin life and what have been the major emotional and sexual influences since birth?  This essay is about your personal and sexual evolution – it is likely to be at least a couple pages long, and should include an overview of the following:


Mail your application and the enclosed informed consent form to
IPSA Training Coordinator
3428 Motor Avenue
Los Angeles, CA 90034