Registration Form Adult Mindful Self-Compassion 8-Week Workshop – Summer 2016, Grand Junction, CO Mondays beginning June 13, 2016 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 Email* Phone (home)*Phone (cell)*Date of birth MM slash DD slash YYYY Your gender Female Male Partnership StatusSingleMarriedDivorcedPartneredOtherEducationHigh SchoolCollegeGraduateWhy are you interested in participating in this program?*Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? (It’s not necessary to have any experience of meditation prior to this program.)*How would you describe your physical health?*excellentgoodfairpoorAre you currently in psychotherapy? If so, please provide the name and telephone number of your therapist.Are you currently taking psychoactive medication, or any medication that may affect how you feel from one week to the next? (If so, please provide details.)*If there is anything else that would be helpful for the instructors to know at this time, please let us know here.How did you hear about this course? Please be as specific as possible.*Ex: Past participant, Google search, flier, your employer, CMSC website, etc.Would you like to receive our periodic newsletter?*We will never share your email address. Yes, please No, thanks. 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 fee. At the present time, however, I am planning to participate in the entire course (including the retreat), and to practice mindful self-compassion at least 30 min/day (formally or informally). I understand that this is not a group therapy program.* 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! Reset signature Signature locked. Reset to sign again Date of signing* MM slash DD slash YYYY Payment Details:Mindful Self-Compassion 8-Week Course Registration Quantity* Price: $325.00 Quantity How would you prefer to pay?* Debit or Credit Card Check IF YOU ARE PAYING BY CHECK, please mail your check to: Skip Hudson, LLC 587 1/2 Grand Cascade Way Grand Junction, CO 81501 Checks should be received within 7 days of registration in order to hold your space in the workshop. Full payment must be made prior to the date of the first class.Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.
