Mindful Practice in Medicine Facilitator Training Workshop Application Dec 2021

Returning?

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Eligibility Requirments:

Prior attendance at a Mindful Practice® Workshop of 20 hours or more. This requirement can only be fulfilled by having attended a virtual or residential, 4-day Mindful Practice® workshop (residential options include: Chapin Mill Retreat Center, or similar workshops in Norway, Sweden, Hong Kong or the Netherlands).
Active meditation practice
Experience teaching health profession students, residents and/or practitioners

This Workshop is limited to 24 participants.

Registration Fee:

Early-bird (extended to November 8, 2021) - $2,795

Regular fee (as of November 9, 2021) - $3,195

Application Process:

Please complete the application below.
Upon pressing the Submit button, we will receive your application.
Applications will be reviewed monthly, starting May 1, 2021, based on space availability.
After May 1, on acceptance, an email will be sent to you with a registration link to register for the course.

1. First and Last Name:

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2. Title:

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3. Academic Affiliation or Organization Name:

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4. Degree

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Other:

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5. Email Address:

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6. Mailing Address:

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7. Telephone Number (and/or cell phone number):

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8. How did you learn about the workshop?

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Please specify:

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9. What has led to your interest in attending this Mindful Practice Facilitator Training Workshop?

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10. Have you been to a prior Mindful Practice Workshop?

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Yes

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When?

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11. Have you attended other mindfulness training workshops, such as an MBSR course?

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Yes

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Which course? And when did you take the course?

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12. Do you have a regular meditation practice?

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Yes

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For how long?

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Please describe your meditation practice:

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13. Have you participated in any teacher training or faculty development that emphasizes small group learning?

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Yes

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Please describe:

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14. Please list any other relevant experiences:

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15. Large group presentations:

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16. Small group teaching and facilitation:

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17. Teaching meditation:

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18. What are your goals in attending? Please describe up to 3 goals:

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19. How do you plan to incorporate what you have learned into your professional life?

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20. Please share any other information that might be relevant:

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