Developing Teaching Skills Booking Form

Developing Teaching Skills

Registration Form
Booking Information
OpenCRM Event
Choose your dates below:*
Please select the rate you will be paying:*

IndividualOrganisationConcessionI would like to pay the Stage 1 BundleI have already paid the Stage 1 Bundle
If an organisation is paying, please provide invoicing details:
To pay the Stage 1 Bundle, you must fill in the more detailed application form for Mindfulness Facilitator A so we can assess whether you have fulfilled all the prerequisites for Stage 1. You can access the form here.
Stage 1 Bundle means paying for all Stage 1 modules at once and receiving a discount of 10%. If you would like to request a payment plan, please let our training team know by email when they confirm your place.
Please tell us some basic information
Name:*

First NameLast Name
Address*

Street Address

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

DayMonthYear
Gender*
What pronouns do you use?
Ethnicity*
Your Practice
I am taking Developing Teaching Skills...

as part of my Breathworks Teacher Trainingto develop my skills after completing Champions or Facilitators Trainingto prepare for Champions or Facilitators trainingto continue developing my skills as a practising teacheras CPD
Please tell us if you have trained to teach any of the following:

MBSRMBCTDBT (Dialectical Behavioral Therapy)ACT (Acceptance and Commitment Therapy)Breathworks 8 week courses
Please tell us a bit about what you hope to get out of your experience on the 'Developing Teaching Skills' course*
Will you be continuing on to take the full Breathworks Teacher Training?

YesNoUndecided
Health and Accessibility 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?
If you have particular access or communication requirements which need to be met in order for you to engage fully with the Breathworks training programme (eg. related to dyslexia, physical or mental health conditions, sensory impairment, restricted mobility etc). Please give details:
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
How did you hear about Breathworks*

Friend / family memberDoctor / hospital / medical professional / therapist / counsellorWork / colleagueInternet search (Google or other)Social mediaMentioned on another websiteIn the newsOther (please specify)
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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Developing Teaching Skills

Booking Information

Please tell us some basic information

Your Practice

Health and Accessibility Information

Emergency Contact

Keeping in touch