Step 1 of 5 20% Course Details Name Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code 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 Country Home PhoneMobileWork PhoneEmail Website if applicable Occupation or role related to your application Relevant Work History*Education/CertificateCompletedLength of Training Formal Relevant Education, Qualifications and Trainings: 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 If "yes" please give details below and indicate how we might be able to support your learningDetailsWhere 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 If yes, which course was it? Where? When? Name of Tutor/Online (Please note that acceptance on the course is subject to you providing MindfulnessUK with your course-relevant certificate of attendance.) Tell us about your current mindfulness meditation practice, including both formal and informal practices Do you have any logistical, health or practical requirements that may need support by MindfulnessUK? Please let us know these details on application via info@mindfulnessuk.com* Yes No (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.) Financial Obligations and Cancellation Policy MindfulnessUK courses are very popular and cancellation of your place on the course needs to be in writing to info@mindfulnessuk.com. A place will only be booked for you onto the course on completion of the application form and payment of the first instalment. If your application is unacceptable, this first payment will be refunded. If you cancel your place more than 4 weeks before the start of the course then this first payment will be refunded minus a £100 administration charge. If you cancel your place less than 4 weeks before the start of the course the first payment will not be refunded. Declaration 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 18 years old.Print Name Date MM slash DD slash YYYY Δ