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About the Course
Course Dates/ Fees
Prefered First Name
Date of Birth (DD/MM/YYYY)
Emergency Contact (please include a full name and contact number)
Do you have any special access mobility requirements?
Do you suffer from any physical health conditions (including asthma and epilepsy)?
Do you have any restrictions in physical movement (including stretching and walking)?
Do you, or have you had any serious mental health conditions that we should be aware of? If so please provide details:
Are you on any on-going medication that we should be aware of? If so please provide details:
Do you have any further requirements that we have not listed, or is there anything else we should be aware of? If so please provide details:
Please let us know briefly about yourself and your interest in becoming a Mindfulness teacher?
Your Course Start Date (DD/MM/YYYY)
Please tick here to confirm that the information you have provided here is accurate to the best of your knowledge.