Mindful Movement Non-Student Booking Form 2024

Mindful Movement

Registration Form
Please confirm that you are not currently a student on our Mindfulness Facilitator or Teacher Training programme and wish to do the Mindful Movement workshop as a standalone course:*
If you are a student on our Mindfulness Facilitator or Teacher Training programme, please fill in this form instead https://form.jotform.com/232344583478363
Payment Information
Choose your dates below:*
OpenCRM Event
Please select the rate you will be paying:

IndividualOrganisationConcession
If an organisation is paying for your course, please provide invoicing details
Please tell us some basic information
Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
E-mail 2
example@example.com
Mobile Phone*
Home/Work Phone

Area CodePhone Number
Date of Birth*

DayMonthYear
Gender*
What pronouns do you use?
Ethnicity*
Tell us about your practice
Please tell us about your previous mindfulness training or experience*
Please tell us about what you hope to get out of the Mindful Movement course?*
Further Information
Do you currently have any physical health conditions?*
If yes, how does this condition affect your ability to hear, see, sit, stand, walk or engage in mindful movement?
Have you had any mental health issues within the last few years (such as anxiety or depression)?*
If yes, have you ever, or are you currently receiving treatment?
Is there anything else you'd like to share with us?
We want to make sure that your Breathworks training is as accessible as possible. If you have any access or communication requirements (eg. related to dyslexia, neurodiversity, physical or mental health conditions, sensory impairment, restricted mobility etc) please give details here:
Emergency Contact

Please provide contact details for who we should contact in case of an emergency when attending a programme with us.
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
If there is an incident/accident/ flare up of your health condition during one of our events, is there anything we need to know to help get you the support you will need? eg list of medication, usual steps you take
Keeping in touch
Communication Preferences

We'd love to add you to our mailing list so you can enjoy our monthly mindfulness newsletter and be the first to know about events & promotions we think you'll love. We'll keep you present, not pestered. If you're happy to hear from us, please tick the box below.
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Newsletter
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Date of submission

MonthDayYear
Contact Type
Activity status
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Mindful Movement

Payment Information

Please tell us some basic information

Tell us about your practice

Further Information

Emergency Contact

Keeping in touch