Confirmation Form for Six-Week Mindfulness Meditation Series

Please note that you have an option to 'not' answer any or all of the questions pertaining to Age, Race, Gender Sexual Orientation or psychological conditions. We request this information so that we can create greater inclusivity, diversity and safety in our group container. 
Your answers to the following questions will remain confidential and only available to the teachers of this series.

Name *
Name
Examples: Male, Female, Transgender, Genderqueer or Genderfluid
(e.g. psychological conditions, physical conditions, fasting, recent loss of a loved one, substance dependency/withdrawal, relationship ending)?
EG: LGBTQI
We request you to make your payment as soon as possible as we have limited spots available. Payment of your fee confirms your attendance to the series. Please make a payment and choose from the options below:
 
 
Send Payment to paypal.me/BrettWheeler

Send Payment to paypal.me/BrettWheeler

 
Send payment to niralis@gmail.com

Send payment to niralis@gmail.com