Please note: This information will only be read by the course instructors. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins or leave it blank. Leaving a question blank will have no impact on inclusion in the program. Thank you.

Course Thursday mornings 10:00 am - 12:30 pmThursday Evenings 6:15 pm - 8:45 pm

Name *

Address *

City *, State * Zip *
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Your Email *

Phone *

Date of Birth (YYYY-MM-DD format)

Partnership Status SingleMarriedDivorcedPartneredOther

Occupation

Education High SchoolCollegeGraduateOther

Why are you interested in participating in this program? (Please be advised that MSC is designed for personal growth and development.)

Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? (It’s not necessary to have any experience of meditation prior to this program.)

How would you describe your physical health?
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Are you currently in psychotherapy? (If so, please consider including the name and telephone number of your therapist.)

Are you currently taking psychoactive medication, or any medication that may affect how you feel from one week to the next? (If so, please provide details.)

Is there anything else that would be helpful for the instructors to know at this time?

I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice, except for the non-refundable course fee. At the present time, however, I am planning to participate in the entire course (including the retreat), and to practice mindful self-compassion at least 30 min/day (formally or informally).

Name (required):

Dated (required): (YYYY-MM-DD format)

* = required information

Click the Register and Pay Now button below to register. You will be given instructions for how to securely pay to complete you registration.

You registration will not be complete until payment is processed.

When ready, click the Register and Pay Now button. Thank you!