Working with Mindfulness Programme

Registration Form

Please submit this form fully completed. The information provided in this form is for our eyes only and will be held in the strictest confidence. The facilitator may contact you if further clarification is needed on the details provided below.

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*Name:*

*Work Email:

*Personal Email:

*Organisation:*

*Position:*

*Contact Number:*

*What benefits do you hope to get from this Programme?*

*Have you previous meditation/mindfulness/yoga practice experience? If yes, give details.*

*Are you presently on any prescribed medication we need to be aware of? If yes, please give details.*

*Any other relevant information you feel we should be aware of, for example a recent loss or major life change.*

Date: