Teach .breathe Application Teach .breathe Application Complete the Application Form Please read each question carefully, and respond as fully and accurately as possible. Please select the Teach .breathe course you are applying for*Select courseTeach .breathe — London — 04 Oct 2019Teach .breathe — Solihull, near Birmingham — 09 Oct 2019Teach .breathe — London — 30 Oct 2019Teach .breathe — Liverpool — 26 Nov 2019Teach .breathe — Manchester — 27 Nov 2019Read the .breathe Terms and Conditions Read the .breathe prerequisitesI have read, understand and fully agree to the Terms and Conditions and prerequisites for taking part in this training course and confirm that I meet these prerequisites and agree to the ongoing commitments as a .breathe teacher as described.* I have read the .breathe Terms & Conditions I have read the .breathe prerequisites Name (This will be the name used on your certificate)*Email address for course communication*House number or name*Street*Town or City*County or state*Postcode*Country*Please selectUnited Kingdom—AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweRegion*Please selectEastern EnglandEast MidlandsLondonNorth East EnglandNorth West EnglandSouth East EnglandSouth West EnglandWest MidlandsYorkshire and the HumberScotlandWalesNorthern IrelandChannel IslandsHome telephone number (please include country code)*Mobile telephone number (please include country code)*Emergency Contact:Name*Number (Landline)*Number (Mobile)*Employment & Funding:Your Profession*Your Employer*Your Employer's Postcode*Is your employer*A maintained school (incl. grammar school) or academy chain in the UKAn independent school in the UKA council, LEA or other governmental bodyA non-UK school or other international educational bodyOther (please specify)I am self-employedPlease specify*How is your attendance being funded?*Self-fundedMISP supported placeOtherOther Information:Do you have any physical illness (including allergies) or other issues that may make sitting, standing, walking or doing simple mindfulness practices difficult for you? If yes, please tell us about it.*YesNoPlease explain*Are you currently taking any medication which could have an impact on your participation on the course? If yes, please provide more details below.*YesNoPlease explain*Do you have any difficulty with sight or hearing? If yes, please tell us about it.*YesNoPlease explain*While this course is very much an introduction to mindfulness, there will periods during the day when we engage in brief mindfulness practices. If there are any aspects of your life, e.g. recent mental health issues, trauma or major life events, that you feel may affect your participation in, or experience of, the course please do let us know by contacting email@example.com. Please be assured that any personal information you disclose will be treated in the strictest confidence.To my knowledge, there are no personal mental health issues, trauma or major life events that are likely to affect my experience of this course.*AgreeDisagreeNot SurePlease explain*Have you had any previous experience of mindfulness?*YesNoPlease tell us about your experience of mindfulness*If there anything else you think it would be helpful for us to be aware of, please feel free to use the box below to outline this.To secure a place payment is due within 2 days of receiving the invoice.To secure a place payment is due within 2 weeks of receiving the invoice.Enter the code received from MiSP charity team*Please provide the name and address of the organisation and the contact name and email address of the person we should send the invoice to:Organisation name*Organisation address*Contact name*Contact email address* Where did you hear about this course?* Your school Another organisation A friend A MiSP Leaflet A MiSP email A Facebook advert A MiSP event or stand Internet search MiSP on Facebook MiSP on Twitter MiSP on Linked In Other Please enter the search term used*Please state*Please confirm you are over 18 years of age* I confirm that I am over 18 years of age Please confirm your level of English* I confirm that I am able to speak and understand English to an Upper Intermediate Level, i.e. I am able to interact fluently with native speakers, communicate effectively and understand everyday language without the aid of an interpreter. We’d love to stay in touch.*I’d like to be kept up to date once I have completed Teach .breathe so I can find out about what’s on offer in the HUB, MiSP news and events, SIT groups and training with MiSP in the future.I’d prefer not to be contacted This iframe contains the logic required to handle Ajax powered Gravity Forms.