Course Details: 8 Week Mindfulness Course Tuesday 4th January, Monday 9/16/23/30th January, 6/20/27th February 2017 (3.00-4.30pm) Day retreat at Chalfont St Peter Academy (10am-4.00pm) on Sunday 19th March 2017 Your Details: Name (required) Telephone (required) Email (required) Address Postcode Year of Birth Occupation Please tell me how you heard about the course (if by internet please specify which site): Payment: Course Cost: £695 Full Payment is required at time of booking to secure your place. Bank transfer (payable to: Co-operative Bank A/c 12306145 S/c 089103). Please ensure you put your name in the reference box so your payment can be identified. Health Questionnaire: To help me guide you on this course, please complete this health questionnaire. The information you give is strictly confidential and will only be seen by the course facilitators If brought to the facilitator’s supervision, it will done so anonymously. No information is held long term on any data base and all forms will be destroyed after the course. If you have any physical illness or other limitation that may make sitting, standing, walking or doing simple exercise difficult, please tell me about it here: If you have had any mental ill health within the last few years, such as anxiety or depression, please tell me about it here: If you are taking any medication at present please say what it is and what it is for: If you are going through any significant life events at the moment please briefly say what they are (eg. moving home, loss of job, relationship issues or divorce, bereavement) If you have had any previous experience of mindfulness of meditation please tell me about it here: Please tell me about your reasons for booking onto this course: Booking Conditions: If you need to cancel or re-schedule a session, I will do my best to re-arrange it for another date providing at least 48 hours notice has been given. Cancellations without notice will still be chargeable. The facilitator reserves the right to cancel the course under any circumstances. Should this be the case you will receive a full refund. Signed: Date: If you have any queries about this form, or the course, please contact Gayle Creasey on 07941 279177 By using this form you agree with the storage and handling of your data by this website.