Mini Mindfulness Retreats - Registration Form - Acupuncture, Massage, Mindfulness, Traditional Chinese Medicine: Victoria

Mini Mindfulness Retreats – Registration Form

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Thank you for your time in completing this form so that I can provide a supportive retreat experience. All information shared here will be completely confidential and will only be read by me (Stephanie Curran).

Name*

First Last

Email*

Cell number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Profession

How did you hear about this Mini Retreat series? (please be as specific as possible)*

Have you practiced mindfulness before?*

Yes

If you answered yes above, please list the teachers you have studied with and what programming or retreats you have completed.

What interested you in this series and what called you to register?*

Are you experiencing any major life stressors at this time? (ie medical treatments, death of a loved one, etc)

Mindfulness Workshop Options

Sun.Dec.14, 2025

Sun.Jan.25, 2026

Sun.Feb.22, 2026

Sun.Apr.12, 2026

Sun.May 3, 2026

Sun.June 7, 2026

Mini Mindfulness Retreats

GST

$ 0.00 CAD

Total

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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