Manual 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* 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 TypePassportDriving LicenceID UploadAccepted 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? 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. Please read the full MindfulnessUK cancellation policy here.Financial Obligations, Terms and Cancellation Policy Once you submit this application MindfulnessUK will process it and let you know whether your application is successful or not. Sharpham House deal directly with all other aspects of your payment and booking for this qualification and their Terms and Conditions apply.I 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.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 19 years old. I declare that all information contained within this application form is accuratePrint Name Date
