WI-25 Registration Mindfulness Embodied

First Name

Last Name

International Phone Number

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

Year of Birth

Did you attend MBSR or MSC with Imagine and when?

How did you hear about our Mindfulness Embodies Program?

Do you have regular meditation/mindfulness practice?

Do you have any physical limitations/pain/chronic condition? Please describe.

Do you have any emotional/psychological issues that are not stabilised? Please describe.

How do you understand the concept of Embodiement?

What is your intention/your curiosity to join the Mindfulness Embodied course?

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.