Registration Form For One to One Psychotherapy Counselling Mindfulness Meditation Sessions
Please fill all the sections.
What Sessions you would like to register. Sessions ideally required two hours. We take a contribution One Hour Session £20/= or Two hours full session £30/= for hosting as a donation to the centre.
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Full Name with title: Mr/Miss/Mrs or Other *
Date of Birth *
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Email *
Address with Postcode *
Mobile *
Landline
Name of Next of Kin (In Case of Emergency)
Contact Number of Next of Kin (In Case of Emergency)
This Mindfulness Course is based on Equality Policy which anyone can be participated without any prejudices: In respect of that, we should be grateful if you could provide following details: participated without any prejudices: In respect of that, we should be grateful if you could provide following details: How would you best describe your country of origin or Ethnicity:
Nationality
Faith/Religion/Belief
Profession (Occupation: If this is a self-developed enterprise please describe briefly)
Please give us an indication of your previous meditation experiences or counselling psychotherapy experiences
How did you find us or this course (News Paper Advert/Website/Recommended by a Friend or other)
Why did you choose to follow this course and what do (would) you expect from this in life in the future
Special Needs
Health: Please indicate any current physical health difficulties, and/or any mental health issues, either present or past
Fee: I wish to enclose a cheque/Cash ......... (£30/= for two hours session or £20/= for one hour session) as a contribution towards the cost of the course. Or please note here how you wish to contribute. If anyone wishes to participate in any other form, there will be further opportunities for dana/donations towards our community meditation. Cheques: "Letchworth Dhamma Nikethanaya Buddhist Centre"
Fee: Session Contribution £30/= (two hours session) £20/= (for one hour session). If you have not made the contribution, please use the following bank details to pay the course fee: Sort Code: 20-41-15 Account: 93992683 Barclays Bank PLC, Letchworth A/C Name: Letchworth Dhamma Nikethanaya Kindly set "your name" as online bank reference. All the details are on our website. www.buddhistacademy.com
Further Support One wishes to offer to Our Centre: If anyone wishes to participate in any other form, there will be further opportunities for dana/donations towards our community meditation. Cheques: "Letchworth Dhamma Nikethanaya Buddhist Centre"
14. Gift Aid your donation: Declaration: Letchworth Dhamma Nikethanaya International Centre For Education, Meditation, Psychotherapy and Counselling (LDN) is a registered Charity. If you are a UK taxpayer, completing this declaration by ticking the box, will increase your donations by 25% at no cost to you. Please say YES or NO to the following statement. "I am a UK taxpayer and would like the Letchworth Dhamma Nikethanaya to treat all donations I make on or after 6th April 2000 as Gift Aid donations, and that the Letchworth Dhamma Nikethanaya can claim gift aid on my behalf. "
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Data-Protection: Your information will be treat as confidential to improve our better understanding about you. We would like to retain your information, if you do not wish us to do so, please indicate accordingly: Yes/No
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I wish to register to the a session(s). Please write / sign your name and the date
Please send us a text message or whatsapp message to say that you have filled this form. Otherwise reply could be delayed. Our mobile numbers: 07944 13 53 14 or 07983 466 105 or email us: buddhistacademy@gmail.com Thank you for registering.
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