Deepening and Extending the Foundations of Mindfulness - 25/11/2018 - 02/Dec/2018

Course fees

Deposit to secure my place with SHARED accommodation (inc VAT) - £100.00
Full rate (inc VAT) for SHARED accommodation (2 or more to a room) - £825.00

Venue information

Othona, West Dorset
Coast Road Burton Bradstock Bridport Dorset DT6 4RN UK

This course is residential.

Application information

The Mindfulness Network CIC requires payment by BACS at the point of registration for all courses.

Please visit our terms and conditions page before progressing with your application - Mindfulness Network CIC Finance Terms and Conditions.

If you are in agreement with the terms and conditions, please complete the below registration form as fully and accurately as possible. All information is used for assessment of training suitability only and is not passed on, shared or disclosed to any third party. Occasionally it is necessary for the teacher to contact you in advance of course commencement to discuss any information you may have provided.

By providing the below information and submitting the registration you agree for the Mindfulness Network CIC to store your information on their secure system and share it with the necessary team members to both administer and deliver the required training.

Terms & Conditions

We never share your information however we occasionally send news updates and information to delegates about our forthcoming courses and events. If you would rather not receive this information please tick here

Cancellation Policy:

You may withdraw your application eight weeks prior to the event commencement date at which point you will be offered a refund, minus a 25% admin fee. If you cancel your place on a course within eight weeks of the event commencement date, no refund will be offered.

In the unlikely event that, due to unforeseen circumstances, the course has to be cancelled by us, we will refund any fees paid to us by participants. Our liability is limited to refunding only our event fees. We recommend participants have adequate insurance to cover any cancelled travel or personal expenses.

I confirm by ticking this box I have read the course description and relevant information sheets and understood and agree to the payment and cancellation arrangements of the Mindfulness Network CIC:


About you

Title: Forename: Surname:

Address 1:

Address 2:

Address 3:



Country (if not UK):




Emergency contact:

Telephone number:

Relationship to participant:

Do you have any special requirements?

Please provide further details:

Where did you find out about this course?

Please state:

Your physical health

Please provide the name of your GP:

Please provide the address of your GP:

Please provide the phone number of your GP:

Do you have any current medical conditions?

Please provide further details of your current medical conditions:

Do you have any physical illness or other limitation that may make hearing, sitting, standing, walking or doing simple exercises difficult for you?

Please provide further information about your physical illness/limitation:

If you have significant physical health problems, please tell your GP that you are undertaking the course.

Your mental health

Have you had any mental health issues or concerns within the last few years, such as anxiety or depression?

Please provide further information regarding mental health issues or concerns:

Are you taking any medications or over-the-counter drugs at the moment?

Please list your medications here:

Have you ever received psychiatric or psychological treatment before?

Please provide further information regarding psychiatric or psychological treatment received:

Have you ever made a suicide attempt?

Please provide further information:

If you are currently receiving counselling, psychotherapy or any mental health treatment please tell your therapist that you are undertaking the course.

Alcohol and other substance abuse

Has alcohol or drug use (including over-use of prescribed medication) ever caused problems for you?

Please provide further information:

Experiences of upsetting events

Sometimes things happen to people that are extremely upsetting - things like being in a life threatening situation like a major disaster, very serious accident or fire; being physically assaulted or raped; seeing another person killed, dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to. At any time during your life, have any of these kinds of things happened to you?

Please provide further information:

Sometimes these things keep coming back in nightmares, flashbacks, thoughts that you can't get rid of. Does this happen to you?

Please provide further details:

Do you ever get upset when you are in a situation that reminds you of one of these terrible things?

Please provide further details:

Course fees

Please select the fee that you're paying.

Is your fee to be paid by your employer?

Employer name:

Employer's address:

Employer's postcode:

Contact name at employer:

Contact e-mail address at employer:

Contact phone number at employer:

Do you have a purchase order number - if you are working within the NHS, this is usually necessary:

Mindfulness Practice

Please advise about your duration of personal practice - e.g. under 1 year, 1-2 yrs, 3-5 yrs, 6-10 yrs, over 10 years

Please detail of the style/tradition of practice - e.g. MBSR/MBCT approach, Buddhist tradition (say which), other (give details)

Details of Mindfulness training:
Participation in 8-week course(s) and date(s)

Participation in further 'deepening' courses (give details)

Teacher training (give details)

Are you currently teaching MB courses? If so please give details

Retreat experience
How many previous retreats have you attended, please also detail when, where and approx duration and dates


All meals will be vegetarian, but please let us know if you have any special dietary requirements

Please give details of any previous mindfulness courses, training or retreats you have attended.

Please indicate briefly what you hope to get from this course.

Any other information you would like to pass onto the admin team or teachers in connection with this application: