Mind and Body Wellness Registration Form (Cohort 3)
Please fill out the form carefully for registration to attend our very first 5-week Mind & Body Wellness programme in Blaenau Gwent. The sessions take place on Thursdays between 9.30am and 11.00am at Ebbw Vale Institute (EVI). The first session starts on 15th May 2025, and the final session takes place on 12th June 2025. 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. They have been funded by the National Lottery Players.
Name
First Name
Last Name
Birth Date
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Gender
Please Select
Male
Female
N/A
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Address
House Number/Name & Street Address
Street Address Line 2
Town / City
State / Province
Post Code
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E-mail
example@example.com
Mobile Number
Emergency Contact Name
First Name
Last Name
Emergency Mobile Number
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Past Medical History:
Any Current Health Concerns
Current Medication
Registered GP Practice:
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How did you hear about us?
Word of Mouth
GP
Counsellor or other Health Professional
Flyer / Poster
Internet / Social Media
Newspaper / Magazine
Other
Have you attended any previous Mind and Body Wellness/Breath to Health sessions in Ebbw Vale or Caerphilly? (You can attend as many as you wish).
Yes
No
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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
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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
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