Retreat Details: Mindful Self Compassion Residential Retreat Booking Claridge House, nr. Lingfield, Surrey, RH7 6QH 28 - 30th April 2017 Your Details: Name (required) Telephone (required) Email (required) Address Postcode Year of Birth Occupation Please tell me how you heard about the retreat (if by internet please specify which site): Payment: Single ensuite cost: £385 (£180 payable on booking, £205 payable to Claridge House) Double non- ensuite cost: £365 (£180 payable on booking, £185 payable to Claridge House) Shared Twin ensuite cost: £385 (£180 payable on booking, £205 payable to Claridge House) Non refundable depost of £180 payable at time of booking by bank transfer 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. Once your deposit has been received you will be contacted re room allocation Health Questionnaire: To help me guide you on this retreat, 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 tell me about your reasons for booking onto this retreat: Booking Conditions: The deposit of £180 is non refundable. Please consider taking out cancellation insurance. The facilitator reserves the right to cancel the retreat 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 retreat please contact Gayle Creasey on 07941 279177 By using this form you agree with the storage and handling of your data by this website.