MIR Payment Plan and Scholarship Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your time and interest in our Mindfulness in Recovery® course. Our mission is to provide MIR skills as many people as possible and to make our programs as financially accessible as possible. In alignment with our mission, we offer payment plans and scholarships on a sliding-scale basis for those that need some financial support. To request a payment plan or a scholarship, please fill out the form below.

Email *

Name *

Phone *

Mailing Address for Workbook *

City, State, and Zip Code *

Start Date of the Course *

YYYY

Tell us a bit about yourself and what you hope to get out of the course *

Tell us about your need for a scholarship or payment plan *

For Payment Plan Request of the Course Fee- Please let us know what payment amounts and schedule would be possible.

For Scholarship Request – What amount of discount is being requested from the full course fee?

For Scholarship Request – Are you requesting a payment plan in addition to the discount? If so, please let us know what payment amounts and schedule would be possible.

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