Registration Form

First Name

Last Name

Date of Birth

Address

Postcode

Mobile Number

Email

Emergency Contact Name

Emergency Contact Phone Number

Please tick any of the boxes that apply to you Please tick any of the boxes that apply to you High or low blood pressure Hearing impairment Restricted mobility Anxiety Partially sighted Asthma Other N/A

If 'Other' (please detail)

I confirm the above information is correct I confirm the above information is correct Yes No

Student Signature (type your full name)

Date

Student’s responsibility – Meditation is a safe and effective stress management tool. However, if you have any of the following conditions or are under supervision by the mental health team/health care provider, we will require you to obtain consent from them to attend this meditation course. If you tick “yes” to any of the following contra-indications please either provide a letter from your mental health team/health care provider or alternatively sign the declaration below to confirm you have verbal consent from your mental health team/health care provider. Student’s responsibility – Meditation is a safe and effective stress management tool. However, if you have any of the following conditions or are under supervision by the mental health team/health care provider, we will require you to obtain consent from them to attend this meditation course. If you tick “yes” to any of the following contra-indications please either provide a letter from your mental health team/health care provider or alternatively sign the declaration below to confirm you have verbal consent from your mental health team/health care provider. Clinical Depression Bipolar Epilepsy Schizophrenia N/A

I declare I have made my mental health team/health care provider aware that I am attending a Beginners Meditation course and I agree that will notify my mental health team/health care provider should my health or symptoms change during the course. I declare I have made my mental health team/health care provider aware that I am attending a Beginners Meditation course and I agree that will notify my mental health team/health care provider should my health or symptoms change during the course. Yes No N/A

Student Signature (type your full name)

Date

GDPR regulations - In order to comply with the GDPR regulations can you please tick the boxes below? I agree for you to store my data, for the period laid down by your insurance. I understand that this data will be stored securely and I have a right to withdraw this consent at any time. GDPR regulations - In order to comply with the GDPR regulations can you please tick the boxes below? I agree for you to store my data, for the period laid down by your insurance. I understand that this data will be stored securely and I have a right to withdraw this consent at any time. Yes

I agree for you to use my data so that you can provide me with information about any future courses that you may be running. I agree for you to use my data so that you can provide me with information about any future courses that you may be running. Yes