Course Registration

"*" indicates required fields

1. Personal Information

Forename*

Surname*

Gender*

Age group*

DOB*

Occupation

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Email*

Your telephone*

Please provide the name and telephone number(s) of an emergency contact person:

Name*

Contact number*

Do you have a physical or sensory limitation which might affect your participation?*

Yes

2. Other questions

Are you willing to make time for the full 8-week course?*

Yes

Would you be able to make time up to 30 minutes of personal practice each day?*

Yes

Are you familiar with using Zoom for online learning?*

Yes

Have you experienced with mindfulness practice so far?*

Yes

If yes, please share details of your practice if willing (e.g type of practice, frequency, and lengh of practice).

Where did you hear about the event?

Please specify

3. Health Questions

Do you have any physical health concerns we need to know about?*

Yes

Have you experienced depression in the past 6 months?*

Yes

Are you currently experiencing depression?*

Yes

Have you experienced psychotic episode/s in the past?*

Yes

Have you experienced a manic/hypomanic episode in the past 6 months?*

Yes

Are you currently receiving any psychiatric or psychological treatments?*

Yes

Are you currently taking any Medication?*

Yes

Are you currently receiving any talking therapy?*

Yes

Have you deliberately harmed yourself in the past year?*

Yes

Have you ever attempted to take your own life?*

Yes

Have you ever experienced a traumatic event (death, assault, accident....) which is currently affecting you?*

Yes

Have you experienced bereavement in the past year?*

Yes

Are your currently using alcohol or drugs in order to manage your stress/distress?*

Yes

Are there any current life changes (loss of home, job, relationship breakdown, too many work commitments etc.) that may be placing you under additional stress?*

Yes

If there is anything you would like to explain or for us to know, please note it here.

What do you hope to gain by attending the course?*

Following the submission of your pre-course questionnaire, the teachers may contact you to discuss if the course is appropriate for you to attend this time before making the payment. This is to support your health and safety.

4. Recording the Course

In this phase, the teachers are teaching under the supervision of an Oxford Mindfulness Foundation (OMF) supervisor. This requires the video recordings of the course and will be viewed by the OMF supervisor for the teachers’ professional development assessment. The recording will be treated with strictest confidentiality and immediately deleted after our supervision meeting.

If you have any concerns about this, feel free to contact the teacher at the emails:
Nhi Pham: Nhip.dothi@gmail.com or Saira Khan: saira@mendality.com

5. Fee & Payment

Fee*

Standard rate: $290

Supported rate - for people with low income: $260

Supporting rate – to support others to attend the course with low incomes: $320

Accessibility commitment rate - you propose a rate

Please write the number in $

Payment: We will contact you with details of how to make payment upon receiving this application form. Payment is due on 30 September, 2023.

Refund: Under unforeseen circumstances beyond the applicant’s control arise, preventing participation (force majeure) in the course, the applicant must inform the teachers by email 10 days before the course starts for refund and the refund fee will be paid by the applicant. Later than this, the payment is non-refundable.

6. Terms & Conditions

By proceeding to submit your application, you confirm that all the information you have provided is accurate. You agree to our terms and conditions and understand how we keep your data in terms of General Data Protection Regulation (GDPR). Any further questions should be addressed to Nhi Pham or Saira Khan.

We truly appreciate your time and patience to fill out this form!

Comments

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