Your name: *

First Name

Last Name

Best phone number to use related to this booking: *

(###)

###

####

Address of the educational establishment: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do any of the below apply to the pupils/students who'll be in the meditation session? *

I ask this to make my sessions as accessible as possible. Please ensure that upon arrival for the session anything relating to the items below is passed on verbally where necessary.

High or low blood pressure

Anxiety

Restricted mobility

Hearing impairment

Partially sighted

Other

None of the above

Checking for medical consent for the students who'll be in the meditation session: *

Meditation is a safe and effective stress management tool. However, if the students have any of the conditions listed below or are under supervision by a mental health team/health care provider, you will need to check they have consent from their health care professional to take part in meditation (liaising with parents/carers/guardians where necessary). -Depression -Bipolar -Epilepsy -Schizophrenia

Tick to confirm you take responsibility for checking medical consent as outlined in this question

Staff member will be allocated to the meditation session: *

I have an enhanced DBS Certificate but a staff member should still accompany pupils/students throughout the session.

Tick to confirm a staff member will be present for the session:

Tick to confirm the below in line with GDPR/personal data: *

I give permission for my details in this form to be kept on file (safely stored in line with GDPR regulations) in relation to this meditation session.

I confirm the details I have given on this form are correct.