BCPS Mindfulness PD Application Form

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All information on this form is regarded confidential and is intended solely for training pre-registration and pre-screening purposes. Thank you for expressing your interest in the program.

Last Name *

First Name *

Date of Birth *

YYYY

Male / Female *

Female

Male

Address City *

Address Zip *

Email Address *

Telephone Contact *

Occupation *

Professional Title(s) *

Broward County School or District Department *

Are you the designated Liaison for this Project in your School? *

yes

Required

What do you hope to gain from this training? *

What concerns or limitations, if any, do you have? *

Please confirm Orientation/Pre-screening attendance: *

YES

Required

Are you interested in CEUs for Nurses, Psychologists, Counseling, Social Worker, Family & Life Therapist, Registered Dietitian? *

yes

Thank you for taking the time to fill in this form. We will be in touch to follow up with more information shortly.

For further details and questions email us at bcpsprogram@ahameducation.org.

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