Mindful Self-Compassion 8-Week Class for Adults — Summer 2016, Grand Junction, CO Mondays, June 13 – August 8, 2016 6 – 9 p.m. REGISTRATION FORM Please note: This information will only be read by the course instructors. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program. Thank you.Personal details:Name* First Last Title & Organization Email* Phone (home)*Phone (cell)*Mailing Address* Date of birth MM slash DD slash YYYY Your gender Female Male EducationHigh SchoolCollegeGraduateProvide a statement describing your interest in teaching MFY.*Please describe your personal practice of mindfulness, compassion, and self-compassion. Provide details (date, time, location, teachers) of your participation in at least one 5-day teacher led silent retreat.*Are you currently in psychotherapy? (this will not necessarily preclude your participation in this training).*Are you currently taking medication? (This will not necessarily preclude your participation in this training).*If there is anything else that would be helpful for the instructors to know about you?List the details of the 8-wk or 5-day MSC program you attended (year, location, teachers, etc.).* Have you completed MSC Teacher Training? If so, how many times have you taught MSC? (This is not a prerequisite for MFY Teacher Training).* Describe your experience working with adolescents in a clinical or educational setting? (type, frequency, duration, etc.)? Specifically note any mindfulness or compassion training with pre-teens, teens, or young adults.* Please describe any special needs or accomodations. Agreements:I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice, except for the non-refundable course fees described in the course description. I understand that this is a training for MFY teachers and it is not a group therapy program. I agree that all information above is true to the best of my knowledge.* I agree I do not agree By signing below, I agree that all information above is true to the best of my knowledge.*You may use your mouse, trackpad, or finger to sign your name in the space above. Thank you!Date of signing* MM slash DD slash YYYY Making Friends with Yourself Teacher Training late registration prices* ALL INCLUSIVE: Training, Meals, & Lodging = $1,700 LOCALS OPTION: Training & Meals only = $1,400 How would you prefer to pay?* Debit or Credit Card Check - Payable to Skip Hudson LLC, 587 1/2 Grand Cascade Way, Grand Junction, CO 81501 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.