MBSR Summer 2026 Registration Form

Mindfulness-Based Stress Reduction Registration & Consent Form

Fill out the form carefully for registration
Participant Name*

First/Given NameLast/Family Name
Birth Date*

MonthDayYear
Gender
American Indian or Alaska NativeAsian or Asian AmericanBlack, African American, Africa, or African DiasporaNative Hawaiian or Pacific IslanderWhite or CaucasianLatiné/x/a/o or HispanicOther
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Primary Phone Number*
Format: (000) 000-0000.
Highest Level of Education
Are you (check any that apply)
What is your main reason for participating in MBSR?*
Describe your prior experience with mindfulness (e.g., meditation, yoga, tai chi).
Do you exercise regularly?
How would you describe your sleep quality?
Do you have any physical limitations or concerns that the instructor needs to be aware of? If so, please explain.
Do you smoke or use tobacco products?
How often do you use nonprescription drugs or alcohol?
How often do you drink caffeinated beverages (including coffee, soda, energy drinks)?
Do you have a history of substance abuse?*
Have you received mental health treatment from a therapist or psychiatrist in the past 3 years?*
ADD or ADHDAntisocial personality disorderAnxiety disorder (including OCD, generalized anxiety, etc.)Autism or Asperger'sBipolar disorder or manic depressionBorderline personality disorderDepressionPosttraumatic stress disorder (PTSD) or other trauma diagnosisSchizophrenia or psychosisSeizure disorder, TBI, or other head injuryOther psychological or neurological problemsNone of the above
Considered suicideSought psychiatric helpHad thoughts of death or dyingHad urges to beat, injure, or harm someoneHad spells of terror or panicNone of the above
Consent Form
Informed Consent Agreement

I have been informed about the risks, benefits, and possible side effects of the Mindfulness-Based Stress Reduction Program (MBSR). This includes skill training in meditation methods as well as gentle stretching (yoga) exercises. I understand that I am expected to attend each of the weekly sessions, the daylong session, and to practice the home assignments for 40-60 minutes per day during the duration of the program.

I understand that MBSR is not (and is not intended to be) a therapeutic intervention or medical care, and that my participation in no way constitutes a therapeutic relationship with the instructor. I recognize that the program activities may at times make participants feel vulnerable. I understand that if for any reason I am unable to, or think it unwise to, engage in these techniques and exercises (either during class sessions or as home practice), I am under no obligation to do so. I agree to exercise good judgment and self-care during the program.

Recording and Email Consent

I understand that the instructor may record the session for the purposes of supervision and education. I consent to video/audio recordings being made of these sessions, with the understanding that they will only be viewed by the instructor and her MBSR mentor/supervisor. Every effort will be made to ensure professional confidentiality and that any use of video/audio recordings will be for educational purposes only and in the interests of improving professional standards through research or training.

I understand that the instructor may communicate with participants through email or telephone. I give permission for this form of correspondence.

Acknowledgement and Waiver of Liability

By completing this release and consent I assume all risk for any physical or mental consequences of participating in the program. By signing this release I also specifically and expressly agree to hold harmless, indemnify and release the instructor and her employer from any and all liability for the results of the educational guidance that will be or have been provided. Moreover, I acknowledge that the particulars shared in these classes by other participants are to be maintained as confidential. I will not blog or otherwise report on content shared in these classes in any form of media.

Please sign your legal name below to affirm that you understand and agree to the terms of this informed consent agreement.
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Registration Fee & Payment*

Standard Rate

This is the full program cost

$475.00 Quantity

Scholarship Rate

This discounted rate is available to those who cannot afford the full cost

$325.00 Quantity

Pay It Forward Rate

Helps to offset the cost for scholarship registrants

$600.00 Quantity

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Total

$0.00

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Mindfulness-Based Stress Reduction Registration & Consent Form

Consent Form