Mindfulness Booking Form When applying for this course, the information you provide will be kept securely, regarded as strictly confidential and destroyed 14 months after the course, unless stated otherwise and have gained your explicit consent. It will be used mainly by the facilitator/s for the purposes of knowing requirements you may have and if the course is suitable for you at this time. You may be contacted by Kat to discuss if the course is appropriate for you to attend at this time. If you mutually decide that it is not, you may take the course at a more suitable time or condition. Name* First Last Email* Preferred phone number*Postal address* Address Address Line 2 City/Town Post Code Country 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 Do you have any experience of mindfulness?*If so, please let me have a brief historyHow did you learn about Berry and Bloom*friend referralI've already worked with you 🙂google / internet searchfacebookinstagramThe course will involve some gentle movement. Please specify any limitations that may make it difficult for you to engage in gentle stretching, standing, sitting and walking.*Have you had any mental health issues such as anxiety or depression in the last few years? Please describe the issues as well as the professional support you are getting (if applicable).*If you had a difficult or disturbing life experience in the last year, please specify them. (e.g., bereavement, loss of job or home, major relationship breakdown, etc.)I undertake to be fully responsible for my own health and well-being before, during, and after the course, and agree to bring any concerns to the course facilitators in the first instance, and contact my GP (Doctor) or relevant health professional, should I continue to have concerns about my health and well-being.* Agreed I agree to maintain the confidentiality of any information I gain about other participants during the course.* Agreed Is there anything else you think it would be useful for me to know?Which course are you booking for?* Mondays 12th April - 7th June, 2021 Please select the course fee*The fee as shown is for the course in its entirety. Please pay what you can afford, I am keen to offer Mindfulness to all and do not want finances to prevent engagement. You are required to source the book "Mindfulness: a practical guide to finding peace in a frantic world" before the course begins.subsidised rate - £80reduced rate - £150standard course fee - £220Mindfulness Course Handbook*I have created a colourful, inspirational course handbook to support your home practice during the 8 week course. It can be sent to you as a PDF for you to print at home or follow on a device or I can post you a professionally printed handbook for a £5 surcharge.PDF format - freeprinted handbook - £5Payment Method*Bank TransferCredit/Debit CardPayPalPlease send your payment to: HSBC Sort Code: 40-03-33 A/c 21731831CouponIf you have a coupon code please add it here and click the "Apply" button Total £ 0.00 Credit Card* Card Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.