Mindfulness Ambassador Program Registration Form

1

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

First Name

Last Name

2

Email* This field is required.Please enter your email.

example@example.com

3

Please enter your phone number.* This field is required.

Area Code

Phone Number

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 confirm that you're available Wednesdays from 7-830 PM ET from January 14th to March 4th, 2026.* This field is required.(to the best of your knowledge)

YESNO

8

Please confirm that you're aware that the cost of the program is CAD$400.* This field is required.(please get in touch if cost is a barrier)

YESNO

9

Please let me know if you have any current questions. You can also email me here: hello@groundedphysiotherapy.ca* This field is required.I will be in touch regarding payment in the next 24 to 48 hours.