Application Form
Professional Development Courses & Certificate Programs at The Centre for Mindfulness Studies
Email address
Full Name
Your answer
Telephone (###-###-####)
Your answer
Full Mailing Address
Your answer
Which professional development certificate program(s) are you interested in pursuing?
Required
If you are seeking approval for a specific course, please indicate which course(s).
PROFESSIONAL CREDENTIALS
Do you have a degree?
If so, in what field/discipline?
Your answer
Do you have an advanced degree?
If so, in what discipline?
Your answer
Education & Work Experience
NOTE: It may be easiest to copy and paste this information from the Education section of your CV.
Please provide a summary of your post-secondary education.In 150 words or less, please indicate where and when you studied as well as any degrees, credentials,or certificates obtained.
Your answer
Please provide a summary of your work experience over the last 5 years.In 300 words or less, please state your employer, position, location, and dates.
Your answer
PREREQUISITES
Have you completed an MBCT / MBSR / smartEducation program as a participant?
Please list which program(s) as well as the length, location, dates, and facilitator name(s).
Your answer
Have you completed any formal professional mindfulness training?
Please describe the course(s) including stated objectives and list the length, location, dates, and facilitator name(s). For applicants seeking to enrol in a specific course or retreat, make sure to list the required prerequisite(s) and/or their equivalent(s).
Your answer
Have you facilitated (assisted, facilitated alone, or co-facilitated) an MBCT / MBSR / smartEducation program?
Please indicate which program(s) and list the length, location, dates, number of participants, and co-facilitator name(s).NOTE: ‘co-facilitated’ refers to groups for which you and your co-facilitator had approximately equal levels ofexperience facilitating the program while ‘assisted’ refers to groups for which you were the junior facilitator.
Your answer
MINDFULNESS PRACTICE
Do you have a regular meditation practice?
In 50 words or less, please state the tradition, describe the number of times a week you practice, the typical length of each session, and the number of years you have been practicing.
Your answer
Do you have a mindful movement practice (e.g. yoga, qigong, tai chi)?
In 50 words or less, please state the tradition, describe the number of times a week you practice, the typical length of each session, and the number of years you have been practicing.
Your answer
Have you participated in any facilitator-led silent retreats?
Please list the length, location, dates, and facilitator name(s).
Your answer
STATEMENT OF INTENT
Why do you want to enroll in this professional development certificate program or specific course/retreat?
Please explain in 250 words or less.
Your answer
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of The Centre for Mindfulness Studies. Report Abuse - Terms of Service - Additional Terms