Mindfulness for Primary Infertility Registration

Place of residence (what province/ state/ country will you be logging in from?)*

This informs us which time zone applies to you.

Name*

First Last

Best phone number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Confirm Email*

Emergency contact name & phone number*

Primary care physician or therapist name & phone number*

How did you hear about this course? We would love as much specific detail as possible (eg. online search, Instagram feed, Facebook group, friend, name of healthcare practitioner referral, etc)*

Which of the following best describes your situation?*

Please tell us a little about yourself, your fertility journey, and what brings you to this class at this time.*

Please check the box(es) that apply to you:*

Briefly describe any major stressors, worries or concerns in your life.*

What are three ways you hope to benefit from this course?*

Do you have anxiety or depression, suicidal episodes, post-traumatic stress, borderline personality disorder or active drug/alcohol dependency? If so, please describe and list any supports you have worked with in the past or are currently engaged with now.*

Are there any health conditions or physical limitations that are a concern for you? Or may interfere with your ability to fully participate in the mindful movement/gentle yoga (stretching) portion of this course? If yes, please describe and share what adaptations you might need.*

On a scale from 1 to 10 how certain do you feel that you can commit to approximately 45min minutes of daily practice, 5-6 days a week while you are in the program? Please select a number.*

** Please take a moment to mark all sessions in your calendar **, including the full day retreat. Are there any dates you know in advance you will miss class?*

NO - I can attend all sessions
YES – I will be missing a class(s)

Please list date(s) with conflicts:

Consent & Waiver*

I understand that this Mindfulness for Fertility (MFF) Program includes skill training in meditation techniques 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 classes or at home, I am under no obligation to participate in them. Furthermore, I understand that I am expected to attend each of the eight (8) weekly sessions, the Day of Mindfulness session and to practice the home assignments for an hour or more per day during the duration of the training program. This agreement releases the instructors (Stephanie Curran & Alda Ngo) from all liability relating to injuries that may occur due to participation in the MBSR Program. By signing this agreement, I agree to hold the above named instructors entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence. I also acknowledge the risks involved in the MFF Program. These include but are not limited to physical injury and emotional distress. I swear that I am participating voluntarily. By signing below, I forfeit all right to bring a suit against the above named instructors for any reason. I will also make every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.

I fully understand and agree to the above terms.

Deposit

A $100 deposit to reserve your spot in the program can be paid securely via Visa/Master Card or through a PayPal account. Please note this deposit is non-refundable after the course begins. Please select your payment method below to complete your transaction. The remainder of your sliding scale fee can be paid at the completion of the 8 week program.

Deposit

Price:

Payment Method

MasterCard

Visa

Card Number Card Number Expiration Date Expiration Date Security Code Security Code Cardholder Name

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Mindfulness for Fertility Intake Form

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Mindfulness for Fertility