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Your booking is NOT complete until we have reviewed your application form.HiddenUser First Name Name* DrMissMrMrsMsProf. Title First Last 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 IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobileWork PhoneEmail* Website if applicable 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 detailsRelevant Work HistoryList*Education/WorkCompletedLength of training/work Certificate* 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?MBSRTTMBSRMBCTIMCCPDMBCTCMROtherWhere? When? Name of Tutor/Online 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 LicenceID 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: DisabilityDo 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* 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.) Nature of disability / requirement Hearing Learning Visual Mobility Other Please provide details Equal Opportunities: EthnicityI would describe my ethnic origin as*Prefer not to sayAsian British BangladeshiBangladeshiBlack AfricanBlack BritishBlack CaribbeanChineseIndianMixed White and AsianMixed White and Black AfricanMixed White and Black CaribbeanMixed Background (Other)Other AsianOther BlackPakistaniWhite BritishWhite EuropeanWhite IrishWhite Non-EuropeanWhite (Other)OtherDo 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
