Mindful Life 8 week MBSR Mindful Life Registration Form – Fall 2020Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Birthday* Date Format: MM slash DD slash YYYY Occupation*Best Way to Contact You*What lead you to enroll in Mindful Life 8 Week MBSR at this time?*During the last year have you been under the care of healthcare provider(s) for any specific issue(s)?*YESNOIf yes, please explain. (All medical information is strictly confidential)List 3 things you hope to gain as a result of completing Mindful Life 8 Week MBSR.*Informed Consent AgreementUpon submission of payment to True Synergy Coaching, I consent to the following:The risks, benefits and possible side effects of the Mindfulness-based Stress Reduction class were explained to me in detail. This includes skill training in relaxation and meditation methods as well as gentle stretching (yoga) exercises. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises either during the weekly sessions in class or at home, I am under no obligation to engage in these techniques nor will I hold True Synergy Coaching, Insightful Culture, or their employees liable for any injury incurred from these exercises. This course is in no way a substitute for medical care or psychotherapy. If it’s appropriate I have consulted with my physician and/or therapist about my ability to participate in this program. I’ve obtained their agreement to enter the program and their support for the duration of the course. I will provide the MBSR teacher(s) with all relevant information about pertinent medical and psychotherapeutic care.Furthermore, I understand that I am expected to attend orientation, each of the eight (8) weekly sessions, the day-long session, and to practice the home assignments for 45-60 minutes per day during the duration of the training program.Consent* I agree to the Informed Consent AgreementPayment Amount*$350$600Mindful Life 8 Week MBSR follows the curriculum and teaching methods set forth by the Center for Mindfulness at UMass Medical School and Mindfulness Center at Brown. The program adheres to this format that has proven results for stress reduction, promoting wellness, and increasing overall wellbeing. Results are variable and largely predicated on but not limited to one’s dedication to the practices over time. Jon Kabat-Zinn’s book Full Catastrophe Living outlines the entire MBSR course and is the text for the course. While you are not required to read the book as part of the course, you may find it useful for reference and as a continued resource. The chapter Attitudes & Commitment as well as speaking directly to the teachers, may be helpful in determining if the course is right for you. Please reach out with questions. Thank you and we look forward to working with you!