Mindful Self-Compassion Registration Form

Mindful Self-Compassion Registration Form
Name *

First Name Last Name
Preferred Email Address *
example@example.com
WhatsApp Phone Number or Regular Phone number *

Area Code Phone Number
Date of Birth *
Preferred Gender Pronoun Expression (if you wish to express these here): e.g. she/her, he/his, they/their, zie/hir.
What interests you in participating in the MSC course at this time? Please be advised that MSC is primarily designed for personal growth and development. *
Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? It’s not necessary to have any experience of meditation prior to this program.
Do you have any physical illness or limitation that may impact your participation in the program? *

Yes No
If yes, please describe. *
Are there any stressful life circumstances that might make this program difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting). *
Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC? If so, please provide details. *
Is there anything else that might be helpful for the instructors to know at this time?
I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice. At the present time, I am planning to participate in the entire course, and to practice mindful self-compassion for about 20 min/day (formally or informally). *

Clear
Today's date *

Month Day Year
Date

Waiver of Liability

·         I voluntarily agree to participate in activities during the online MSC program. I hereby assume all risks of injury to me and my property that may be sustained in connection with activities undertaken during the program.

·         Any costs incurred for health services are my responsibility and not the responsibility of the teachers or the course facility.

·         I further understand that participation in MSC is at the discretion of the teachers at all times. If, in the opinion of the teachers, I am unable to continue to participate productively in the course, I may be asked to leave.  

·         If I am taking prescription medications of any kind and discontinue taking them during the program, this may be grounds to be asked to leave.  

·         I understand that MSC is a compassion skills training program, not group therapy. MSC is designed to teach participants the tools needed to develop and cultivate a mindfulness and self-compassion practice. I understand that MSC does not take the place of personal therapy.

·         By completing this release and consent I assume all risk for any physical, mental and/or emotional consequences of participating in this online course.

·         By signing this release and consent I also specifically and expressly agree to hold harmless, indemnify and release all facilitators and teachers of this program from any and all liability for the results of the educational guidance that will be or have been provided.

·         I understand that no guarantee is made as to the outcomes or results of this educational training program.

·         I understand that personal safety and emotional wellbeing are the foundation of self-compassion training and that I am primarily responsible for my own safety. I will not push myself to do anything that feels distressing or harmful. If I feel overwhelmed, I will stop what I am doing or slow down until I feel comfortable again. If I need to discuss a personal matter, I can consult with a teacher but I understand that the opinions of others are not a substitute for caring for myself in the best way I know.
I sign this of my own free will. I am of legal age and accept the above disclaimer and authorization. By typing my name below, I am agreeing and fully understand the contents of this waiver: *

Clear
Today's Date *

Month Day Year
Date

Emergency Contact Information
Your Name *

First Name Last Name
Emergency Contact Person - In case of emergency, the following person should be contacted: *

First Name Last Name
Relationship *
Daytime Phone *

Area Code Phone Number
Evening Phone, if different

Area Code Phone Number
Emergency Contact Email *
example@example.com

Payment Options
The cost of the course is 350 USD. The discounted price for teachers, health care providers, and essential workers is 300 USD. If paying by PayPal, please enter the code "discount", if the discount applies to you.

If you are paying by Venmo, please send your payment to @jayresphd.

Thank you! We look forward to practicing with you!

Jennifer and Siri

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Mindful Self-Compassion Registration Form

Emergency Contact Information

Payment Options