Registration Form Fall 2025 Monday

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MONDAY (US/EU/Africa/India)
TUESDAY (Oceania)
FALL 2025
Imagine MBSR Registration

September 15 through November 10
MONDAYS starting 3 PM PT / 4 PM MT / 6 PM ET
and TUESDAYS 8 AM AET / 10 AM NZT
Time Zone Converter

(Daylight Savings Time ends on November 2nd in the US. This change might have an effect on the starting time of class for some of you for Week 7 and 8. We will discuss this with you during the Orientation Meeting.)

All Day Retreat for All Classes = Saturday November 1
Instructors: Nancy Barich and Marieke Dejongh

When you hit SEND, you will be asked next to pay your non-refundable $90 Registration Fee. We would also like to reiterate that we operate on a gift-giving basis. Towards the end of the program we will ask you to consider a donation to Imagine. This video on our Donations page explains our philosophy. You will also receive more information during the Information Session.

First Name

Last Name

Email

International Phone Number

City and Country (International Sign Ups) OR City and State (US Sign Ups only)

How did you hear about Imagine's Live Online MBSR Program?

Year of Birth

Emergency Contact Name and Phone Number

Are you currently seeing a therapist?

Our program includes "Meditation in Motion" (based on gently Hatha Yoga and Qigong). Please list any physical limitations or write None.

Do you have any psychological or emotional issues that are not stabilized?

What's important to you?

How does stress or pain affect your daily life?

Please list personal goals for taking this MBSR program.

Please check any that apply to you. * Required

Headaches

Aching joints and/or muscles

Respiratory difficulties

Digestive difficulties

Rapid or skipped heartbeats

Nervousness or anxiety

Lack of concentration or focus

Depressed

Difficulty relaxing

Considering suicide

Feeling desperation or hopelessness

Grieving

Difficulties with anger

Fatigue or weariness

Difficulty sleeping

Current substance abuse

Extreme hearing loss

None of the Above

Please list any of the above that are severe - if applicable.

Please use this space for comments and/or suggestions. (This is optional.)

I have read and understand these risks.

Checking this box and adding my name and today's date below signifies that I agree with the above.

Thank you for your registration! You will receive an email with details. Please proceed to your payment.

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