Mindful High School • Class Registration • MARCH 2021

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Please fill out this form for pre-registration for Mindful High School Online with Myra Smith.

This course is for high school students in grades 9 - 12.

Before completing this form, please make your tuition payment or scholarship request.

Tuition payments can be made via Venmo.com to @myrajeansmith or to Paypal.com to the address myrajeansmith@gmail.com.

The link for scholarship requests is on the
Mindful HIgh School website at http://wwwmindfulhighschool.com

Tuition is on a SLIDING SCALE of $95 - $130.

Each purchase of a course purchases a scholarship for a student in need.

Classes are on Thursday afternoons in April 5:00 - 6:15 pm EST.
~APRIL 8
~APRIL 15
~APRIL 22
~APRIL 29

It is important that you are able to attend all four classes.

All classes meet on the video conferencing platform Zoom.

Once I receive your tuition payment and you complete this form, you will receive a confirmation email with the link to our ZOOM class, and your registration for the Koru app and details about the course texts.

Student Name *

Student Email *

Parent Name *

Parent Email *

Parent Phone Number ***I will only call you if you register for a class and I am not hearing back from you via email. *

Classes are on Thursday afternoons in APRIL 5:00-6:15 pm EST, APRIL 8, 15, 22, 29 *

YES! I can you attend all 4 classes.

I may have to miss a class due to travel, I can let you know in advance. (If you have to miss a class you can watch the recording)

Option 3

Required

***Please pay tuition or request a scholarship before completing this form. I : *

Please tell me how you found out about the class. *

A friend sent me one of your emails

Via the Mindful High School Website

Instagram

Facebook

Nextdoor

Other:

So you can stay informed about upcoming free meditation events, online classes, as well as other opportunities and resources, may I add you to my mailing list? *

Student Yes

Parent Yes

I already receive emails.

Not at this time.

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