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Mindfulness and Meditation
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Name *
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Date of Birth *
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Contact Number *
1st Emergency Contact Name & Number *
2nd Emergency Contact Name & Number *
Please tick any of the boxes that apply to you *
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I confirm the above information is correct. Please sign with your initials and date below. *
Student's responsibility - Mindfulness and Meditation are safe and effective stress management tools. However, if you have any of the following conditions or are under supervision by a mental health team/health care provider, I will require you to obtain consent from them to attend classes. If you tick YES to any of the following contra-indications please either provide a letter from your mental health team/health care provider or alternatively sign the declaration below to confirm you have verbal consent from them. *
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I declare I have made my mental health team/health care provider aware that I am attending Mindfulness or Meditation classes and I agree that I will notify my mental health team/health care provider should my health or symptoms change. Please sign with your initials and date below.
All the information on this form will be treated in the strictest confidence and will adhere to data protection legislation: GDPR 2018. None of your details will be sold or shared with a third party. Your personal information will be securely stored. Please confirm you have read the privacy policy from Mindful Medicine https://www.mindful-medicine.co.uk/privacy-policy *
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