Meditation consent form
Please complete this prior to joining the meditation class.
Name
*
First Name
Last Name
Email
*
example@example.com
Do you have any accessibility requirements?
Do you have any of the following conditions?
*
High blood pressure
Low blood pressure
Fainting/dizzy spells
Asthma
Breathing difficulties
Hearing impairment
Restricted mobility
Partially sighted
Depression
Anxiety
N/A
Other
Please elaborate here on any health issue mentioned above, detailing any concerns on how this may affect meditating and your practice.
Student's responsibility - contraindications
Meditation is a safe and effective stress management tool. However, if you have any of the following conditions or are under supervision by the mental health team/health care provider, we will require you to obtain consent from them to attend this meditation course. If you tick “yes” to any of the following contra-indications please either provide a letter from your mental health team/health care provider or alternatively sign the declaration below to confirm you have verbal consent from your mental health team/health care provider.
*
Clinical Depression
Bipolar
Epilepsy
Schizophrenia
Not applicable
Declaration
I declare I have made my mental health team/health care provider aware that I am attending a Beginners Meditation course and I agree that will notify my mental health team/health care provider should my health or symptoms change during the course.
*
Date
*
-
Day
-
Month
Year
Date
In order to participate in our meditation sessions, we are required by our insurer to collect and securely store certain personal information, including your name, session dates, and relevant health observations. This is necessary for insurance and record-keeping purposes, in compliance with GDPR. For more details on how we handle your data, please review our Privacy Policy at the bottom of the webpage. Do you consent to us recording your name, session dates, and relevant observations for record-keeping purposes, in compliance with GDPR and our insurer's requirements?
Yes, I consent to the collection and processing of my personal data as outlined above.
No, I do not consent (I understand that this means I cannot participate in the sessions).
Continue
Should be Empty: