Mindfulness-Based Stress Reduction Waitlist, Registration Form and Waiver
Please read over the class description listed on Denise's website and complete the registration form and waiver below.
All information will be kept confidential.
Email address *
Name *
Your answer
Date of Birth *
Your answer
Address *
Your answer
Cell/Home phone numbers and best time to call. *
Your answer
Email address *
Your answer
Emergency Contact Info (name and number): *
Your answer
Please tell me a little about yourself. Briefly describe the major stressors, worries or concerns in your life (i.e. what brings you to the Mindfulness Meditation class at this time?). Feel free to use as much space as necessary. *
Your answer
Please list the specific changes that you hope will come as a result of this course. *
Your answer
Do you have anxiety, depression, a mental illness or an active drug/alcohol dependency? *
Your answer
Are you currently under the care of a mental health professional? If so, please describe your current situation and list the professional that is caring for you and his/her phone number. If you are under the care of a mental health professional, have you discussed taking this class with him/her? *
Your answer
Are there any health conditions that would interfere with your ability to fully participate in the mindful movement/gentle yoga (stretching) portion of this course? If yes, please describe your limitations and what adaptations you might need. *
Your answer
I understand that: (Please read and check all boxes.) *
Required
MBSR Class Waiver of Liability: I declare that the information I have given above is true and correct. I understand that there are risks inherent to any wellness program. Such risks include, but are not limited to, risk of slip, trip, fall, personal injury, and health problems, such as cardiac arrest or stroke, any of which could result in serious bodily injury or death, and I willingly and knowingly assume those risks. I knowingly and voluntarily release and hold harmless, for myself and my heirs, Denise Kozikowski, PhD, RYT from any claim, liability, demand, action and cause of action whatsoever. I further agree to indemnify Denise Kozikowski, PhD, RYT and the insurers against any claim, liability demand, action, cost, damages and expenses to which they are or may be liable. *
Required
Cancellation Policy for the 8-Week Class Cancellations: Denise will refund the class fee in full if the cancellation is made at least 7 days before the first class. There is also an option to apply the fee as a credit toward a future class. Once the class has begun, Denise will issue a refund for: ● 75% of the fee if notice is given immediately after the 1st class ● 50% of the fee if notice is given immediately after the 2nd class. No refunds will be issued after the 3rd class. *
Required
Please type your full name and the date in the space below.
Your answer
Thank you very much for completing the Registration Form.
Denise will contact you shortly to set up a time for a phone interview.
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