Mindfulness Ambassador Program Interest Form

1

Name* This field is required.Please enter your first and last name.

First Name

Last Name

2

Email* This field is required.I will be in touch to let you know when the next round of the program is scheduled.

example@example.com

3

What timezone are you located in?* This field is required.(Please choose one option.)

Eastern (Toronto/Ottawa/Mtl)

Atlantic

Central Daylight (Winnipeg)

Newfoundland

Mountain (Edmonton/Calgary)

Pacific

Other

4

Which day(s) of the week work best for you to participate in this program?* This field is required.(Can choose multiple options.)

Monday

Tuesday

Wednesday

Thursday

Friday

Other

5

Thank you for your interest in the program. How did you hear about it?* This field is required.

6

Please tell me a little bit about what interests you about the program.* This field is required.

7

Please let me know if you have any current questions. You can also email me here: hello@groundedphysiotherapy.caThank you!