Course Application (IMC) Step 1 of 8 12% Please begin your application form by pressing the button below. Once you have advanced to the next page, you may come back and complete this form later. Your booking is NOT complete until we have reviewed your application form.HiddenUser First Name Name*Your full name as declared on ID, this is the name which will be on your official Certificate on passing the course. Title DrMissMrMrsMsProf. First Name Last Name Date of birth MM slash DD slash YYYY Preferred NameWhat you would like us to call you Gender Identity(hover for dropdown selection)Prefer not to sayFemale/She/HerMale/He/HimNon-BinaryAddress* Address Address2 Town County Postcode/ZipCode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PhoneSecond PhoneHiddenWork Phone HIDDEN AS NOT IN USEEmail*the email you booked with Organisation (If funded through employer) Occupation or role related to your application We promote equality, inclusion and diversity so have flexible payment plans. Do you need to talk to us about ways to make the training more accessible to you? Yes No Please provide detailsWork and Qualification HistoryLevel 3 or above qualifications required in any subjectList*Place of workDatesQualification/Training Details (level 3+ or relevant to this qualification) Certificate (Must be level 3 certificate or above)* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 125 MB. Please upload any certificates of relevant work or training (max file size 19.5MB) Where did you find out about this course and how do you intend to use your accreditation once you have completed the course?Have You Completed an 8-week teacher-led Mindfulness-Based Introductory Programme eg MBSR/MBCT?* Yes No Which course was it?*MBSR (8 week)MBCTCMROther (self taught)Where?* When?* Name of Tutor/Online (if self taught put yourself)* Do you have a personal regular Mindfulness meditation practice that you have sustained for 6 months or longer?* Yes No Tell us about your current mindfulness meditation practice, including both formal and informal practices* Learner Photo ID: please scan a copy and upload (One form of ID required)ID Type*PassportDriving LicencePassport/Drivers Licence Number* ID Upload*Accepted file types: jpg, gif, png, pdf, Max. file size: 125 MB.Please upload your identification - PASSPORT or DRIVING LICENCE ONLY please (max file size 19.5MB) Equal Opportunities: DisabilityHealth & Disabilities*Do you have any disability, health or practical requirements that may need support by MindfulnessUK? Please let us know these details on application via info@mindfulnessuk.com (We find it helpful to know some details of your relevant health history so we can ensure safety for you and others, and to support your learning. Please let us know if there is anything we need to be made aware of to either by completing the section below or contacting us at MindfulnessUK.) Yes No Nature of disability / requirement Hearing Learning Visual Mobility Other Please provide details Equal Opportunities: EthnicityI would describe my ethnic origin as*White British (WB)White Irish (WI)White (Other) (OW)Mixed White and Black Caribbean (MC)(British or otherwise)Mixed White and Black African (MB)(British or otherwise)Mixed White and Asian (MA)(British or otherwise)Mixed Background (MO)(British or otherwise)Asian or Asian British Indian (AI)Asian or Asian British Pakistani (AP)Asian or Asian British Bangladeshi (AB)Other Asian (OA)(British or otherwise)Black or Black British Caribbean (BC)Black or Black British African (BA)Other Black background (OB) (British or otherwise)Chinese (CH)(British or otherwise)White EuropeanWhite Non-EuropeanOther (OT) (British or otherwise)Prefer not to sayHover for dropdownDo you have any logistical, health or practical requirements that may need support by MindfulnessUK? Do you consent to your image or feedback being used in our publicity materials?*Photos, videos, and feedback or testimonials are a good way for us to increase awareness of mindfulness and compassion and they are often taken or captured during teaching sessions and related events. We use this content gathered in publicity materials including printed and online publications, promotional videos, website and social media, PR, promotional materials and advertising. Please choose whether or not you consent to your image or feedback being used. Yes No Declaration I have read and understand the Cancellation Terms and Conditions. I understand that I am committing to the entire MindfulnessUK training programme, its tuition fees and the fee payable to the awarding body (where applicable) and that I am over 19 years old. I declare that all information contained within this application form is accurateI have read and accept all the terms above* I accept By ticking this box you confirm that you have read and accept the financial obligations, terms and cancellation policies specific to your course, which are detailed above.Print Name Date Δ