Mindfulness and Qigong 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 ill-health, such as anxiety, depression or others?

YesNo

3. Is there anything else that you would like us to be aware of?
YesNo

4. What is your experience if any, of mindfulness and Qigong?

5. Healthy snacks and drinks are provided. Do you have any food allergies?

6. Where did you hear about this mindfulness day?