Mindful-Spa: 1-Day Self-Compassion & Mindfulness Course by Miyen Low

Full Name*

Please provide the name as in your Identity card/ passport. This name will be shown in your attendance certificate.

Gender*

FemaleMale

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mobile Phone*

Occupation/Profession*

Organization that you are currently at*

Why are you interested in participating in this course? *

Are there any stressful life circumstances that might make this course difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting).*

Provide us with the name and mobile phone number of an emergency contact in the unlikely event of a psychological emergency.*

Do you have any illness or limitation or taking mediation that may impact your participation in the course? Yes/No. If yes, please describe*

Is there anything else that might be helpful for the teacher to know at this time?

I would like to register*

Early Bird [RM250 per person] before 3rd February 2020Group of 3 or more [RM200 per person]Regular [RM300 per person] 3rd February 2020 onward

Fee including handout, certificate of attendance, lunch and light refreshments.

From where you get to know this workshop?*

Would you like to add more participant(s)?

Second Participant's Information

Full Name of Second Participant*

Gender*

FemaleMale

E-mail*

Mobile Phone*

Occupation/Profession*

Organization that you are currently at*

Why are you interested in participating in this course? *

Are there any stressful life circumstances that might make this course difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting).*

Provide us with the name and mobile phone number of an emergency contact in the unlikely event of a psychological emergency.*

Do you have any illness or limitation or taking mediation that may impact your participation in the course? Yes/No. If yes, please describe*

Is there anything else that might be helpful for the teacher to know at this time?

Third Participant's Information

Full Name of Third Participant*

Gender*

FemaleMale

E-mail*

Mobile Phone*

Occupation/Profession*

Organization that you are currently at*

Why are you interested in participating in this course? *

Are there any stressful life circumstances that might make this course difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting).*

Provide us with the name and mobile phone number of an emergency contact in the unlikely event of a psychological emergency.*

Do you have any illness or limitation or taking mediation that may impact your participation in the course? Yes/No. If yes, please describe*

Is there anything else that might be helpful for the teacher to know at this time?

Fourth Participant's Information

Full Name of Fourth Participant*

Gender*

FemaleMale

E-mail*

Mobile Phone*

Occupation/Profession*

Organization that you are currently at*

Why are you interested in participating in this course? *

Are there any stressful life circumstances that might make this course difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting).*

Provide us with the name and mobile phone number of an emergency contact in the unlikely event of a psychological emergency.*

Do you have any illness or limitation or taking mediation that may impact your participation in the course? Yes/No. If yes, please describe*

Is there anything else that might be helpful for the teacher to know at this time?

Fifth Participant's Information

Full Name of Fifth Participant*

Gender*

FemaleMale

E-mail*

Mobile Phone*

Occupation/Profession*

Organization that you are currently at*

Why are you interested in participating in this course? *

Are there any stressful life circumstances that might make this course difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting).*

Provide us with the name and mobile phone number of an emergency contact in the unlikely event of a psychological emergency.*

Do you have any illness or limitation or taking mediation that may impact your participation in the course? Yes/No. If yes, please describe*

Is there anything else that might be helpful for the teacher to know at this time?

For group registration with more than 5 participants, please submit 2 registration forms.

The price remains RM200 per participants as long as the submission is in group of 3 and above.

Thank you.

Terms and Conditions

Registration: Due to limited availability of seats, reservations pending payment will be automatically released after 3 days unless proof of payment is received. Therefore, please inform us via phone or email, with the program title, once payment is made. Your registration will only be confirmed after we acknowledge receipt of payment. Payments after the early bird date must be in full fees regardless of reservation made during the early bird period. Fees for group registrations are to be made collectively.

Cancellation/Refund Policy: Any cancellation done after the confirmation for registration is NOT refundable. However, the confirmed seat may be transferable to a third party once it is made known to InPsych.

Organizers reserve the right to postpone or cancel the program, or change workshop venue within Klang Valley without prior notice. In the event of cancellation by the organizers, a full refund will be provided, but without further compensation and/or reimbursement from the organizers.

For further inquiries, please email us at inquiry@inpsych.com.my with "MSC2003" or contact us at 017-331 1216.

Informed Consent: I understand that my participation in this Mindful-Spa course is entirely voluntary and I am free to withdraw at any time during the course, except the fee is non-refundable. At the present time, I am planning to participate in the entire course. I am also aware that by clicking the "submit" button at the bottom, it means that I have understood and I am agreeable with the terms and conditions, as well as the informed consent.

I have read the terms and conditions*

I accept

MINDFUL-SPA: 1-Day Self-Compassion & Mindfulness

Registration Form: Mindful-Spa: 1-Day Self-Compassion & Mindfulness