REGISTRATION FORM

Inspire Mindfulness, Mindfulness for Stress Course

We would appreciate you filling in this form and providing us with some personal details. This is so we can compile a database, so we can keep you informed of Inspire Mindfulness events in the future and also so we know who to contact in the unlikely event of you becoming unwell whilst attending a session of the course.

Any information you provide will be treated confidentially. Your details will be stored on our computer database, but not passed onto a third party.

NAME (required)

ADDRESS

TELEPHONE

MOBILE

EMAIL (required)

Please tell us who we should contact in case of an emergency when attending a programme with us

Emergency Contact Name

Emergency Contact Landline

Emergency Contact Mobile

What has brought you to choose this course? Please answer briefly.

Do you experience acute, or debilitating depression, or other mental health conditions? If so, can you say a little more about this?

Are you OK to work alongside others in a group situation? * Please note that the group size varies.

Are you able to practice Mindfulness exercises/techniques for at least 20 minutes for the
duration of the course?

Do you have any particular needs that it would be useful for us to know about e.g restricted mobility, hearing, or visual impairment?

We will be giving out recordings during the course. Which format would you like these on?

CDsMemory StickDownload Link

How did you hear about the course? This will help us monitor marketing budget.

Please add any additional comments here:

Thanks-you for taking the time to complete this form.