Mind and Body Wellness Registration Form (Cardiff Cohort 1)
Please fill out the form carefully for registration to attend our 5-week Mind & Body Wellness Programme in Cardiff. The sessions take place at Kings Road Yard in Pontcanna (CF11 9DF) either Wednesday evenings (6pm-7pm) or Thursday daytime between 10am and 11.30am for 5 consecutive weeks, starting 16th July or 17th July respectively. All information you provide will be handled in strictest confidence and in line with GDPR guidelines. There is no fee to attend these weekly sessions.
Name
First Name
Last Name
Birth Date
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Please Select
Male
Female
N/A
Back
Next
Address
House Number/Name & Street Address
Street Address Line 2
Town / City
State / Province
Post Code
Back
Next
E-mail
example@example.com
Mobile Number
Emergency Contact Name
First Name
Last Name
Emergency Mobile Number
Back
Next
Past Medical History:
Any Current Health Concerns
Current Medication
Registered GP Practice:
Back
Next
Which sessions are you registering for?
Wednesday Evenings 6pm-7pm
Thursday Mornings 10am-11.30am
How did you hear about us?
Word of Mouth
GP
Counsellor or other Health Professional
Flyer / Poster
Internet / Social Media
Newspaper / Magazine
Other
Back
Next
Terms & Conditions
I confirm that I am participating voluntarily in the Mind and Body Wellness Programme
Agree
Disagree
By attending the 5 weekly sessions, I understand that when undertaking any breathing or yoga exercises, as is the case with any physical activity, the risk of injury is always present and cannot be eliminated. I voluntarily and knowingly recognise, accept and assume this risk.
Agree
Disagree
I have fully disclosed to the Instructor any conditions that I have or may have prior to participating in these Mind and Body Wellness sessions. Whilst it is acknowledged that personal injury and/or death resulting from negligence cannot be legally waived, I release and waive any other claims for negligence that I may now or hereafter have against Thriving Communities or the Mind and Body Wellness Project Team.
Agree
Disagree
Back
Next
Photography & Data Permissions
Thriving Communities and the Mind and Body Wellness Team may take photographs of me for any promotional materials including any of the following: social media, websites, flyers/posters. I understand I will not be identified by name.
Agree
Disagree
I agree to be added to an email list to be kept informed of future Thriving Communities and Mind and Body Wellness programme events (including the Breath to Health workshop series). I understand that my data will never be shared with a third party, and I can unsubscribe at any time.
Agree
Disagree
The data provided above will be stored and processed in line with GDPR guidelines in order that: my Instructor has knowledge of any injuries when teaching me; and I may be contacted in emergencies. I understand that I can withdraw my consent for my data to be held and/or processed at any time and that to do so I should contact Dr Manmeet Kaur at hello@thrivingcommunitiescic.org.
Agree
Disagree
Submit
Should be Empty: