MBSR Booking Form Your Name* Contact Number* Email Emergency Contact Name* Emergency Contact Number* 1. Do you have any physical illness, disabilities that may make sitting, standing, walking, difficult for you: YesNo 2. Are you experiencing any major life event such as bereavement, divorce, job loss or any major change? 3. Are you experiencing any ill-health, such as anxiety, depression or others? YesNo 4. Is there anything else that you would like us to be aware of? YesNo 5. What has drawn you to undertake this mindfulness course? 6. Healthy snacks and drinks are provided. Do you have any food allergies? 7. Where did you hear about this mindfulness course?