JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Taking it Further Registration
Event Timing: From 2 Oct 2021 to 11 Dec 2021, Alternate Sat [9am to 1pm]
Event Address: SCWO @ 96 Waterloo St, Singapore 187967
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full name (To be shown on certificate)
*
Your answer
Email
*
Your answer
Contact number
*
Your answer
Gender
*
Female
Male
Other:
Age
*
Your answer
Occupation / Designation
*
Your answer
Please state the type of 8-week mindfulness program that you have completed. E.g. MBCT, MBSR etc.
*
Your answer
Please state the mindfulness teacher's name, the year and country in which you completed the program.
*
Your answer
Emergency contact - Name
*
Your answer
Emergency contact - Relationship
*
Your answer
Emergency contact - Number
*
Your answer
Do you have any limitation on your physical mobility that might make sitting, standing, walking or physical activities difficult for you? If yes, please elaborate.
*
Your answer
Are there any present circumstances which might be placing you under exceptional stress, such as depression, anxiety, stressful life changes (e.g. bereavement, loss of home, job etc.)? If yes, please elaborate.
*
Your answer
Are you currently receiving any form of treatment (e.g. psychological or medical treatment)? If yes, please elaborate.
*
Your answer
Why do you want to attend the programme (e.g. physical health, mental wellness, stress, self-development etc.)? What do you hope to gain from the programme?
*
Your answer
How did you find out about this program? (E.g. Word of mouth Referral, social media etc, if by referral, please indicate name of referee.)
*
Your answer
I understand that the registration for the course will only be confirmed after this submission has been reviewed by the facilitators and on payment of the course fees. (Note: The organisers will be in touch shortly with more details after this form is submitted.)
*
Yes
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
