Course Details:
Deepening Practice Mindfulness Group
Wednesday 7th/14th/21st/28th June 2017 (7.15pm-9.15pm)

Your Details:

Name (required)

Telephone (required)

Email (required)

Address

Postcode

Year of Birth

Occupation

Payment:

Course Cost: £119

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 and RAIN in the reference box so your payment can be identified.

Health Questionnaire:

To help me guide you in this group, please complete this health questionnaire. The information you give is strictly confidential and will only be seen by the course facilitator. 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)

Please give a brief overview of your previous experience of mindfulness or meditation here:

Please tell me about your reasons for booking:

Booking Conditions:

The following proportion of your fee, less a £20 admin charge, will be refundable if you cancel your place:

Up to 2 months before the start date: 100%

Less than 4 weeks before the start date no refund will be made.

The facilitator reserves the right to cancel the course under any circumstances. Should this be the case you will receive a full refund.

I understand that in some cases, for unforeseen reasons, participants cannot avoid missing a session of the group. It is not possible to make up missed sessions by joining another group at a later date or to receive a refund if you do not complete the course. It is also not possible to join the group if you are unable to attend the first session.

Signed:

Date:

If you have any queries about this form, or the group, please contact Gayle Creasey on 07941 279177

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