| Event Name |
MBSR (Mindfulness Stress Reduction) class (Guided by Patrick Mitchell)
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| Course Name |
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| Tokyo Mindfulness Center ID# * |
Please refer to your membership card for your number.
*If you are not a member, please fill the box in withthe word "New member" and one-time joining fee of 7,000 yen will be added to your tuition. |
| Family Name * |
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| Middle Name |
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| First Name * |
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| Address * |
Postal code Ex） 000-0000
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| Phone number * |
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Email * |
(If this is your mobile phoneaddress, please make sure to set your device to receive emails from "tokyo-mindfulness-center.jp" as many users have encountered problems receiving our emails usingmobile phone addresses, such as "yahoo.co.jp" or "ymobile.ne.jp".Alternatively, please consider registering with PC e-mail addresses
(e.g., Gmail). |
| Enter the e-mail again to confirm that it is correct * |
|
| Payment method |
*We only accept Visa, MasterCard, and American Express. |
| Yourphysical/mental
condition |
If you had any major injuries and
illnesses, please share with us.
Ex) Knee ligament injury(Cured)
We appreciate if you could share with us
your current physical/mental condition
(e.g., any injuries, sicknesses,
symptoms, medications, and names of
medications if you use any prescribed
medicines.
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Any other comments,
or information you would like
your instructor to know |
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| Consent * |
Personal information you shared will be used for our program administration purpose only. In order to accept our handling of your personal information,
please check the box below.
□ I read the note above and give my
permission for Tokyo Mindfulness
Center to use information I
provided.
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