Professional Development Workshop Intake Form

For Educators, Professional Support Staff, Students, Staff, Community Organization Staff.
Please complete this form so that we can structure our workshop in a manner that best suits your requirements.

1Contact Details > 2Mindfulness Experience
Name of School / Organization *
Tell us about your school / organization…motto / vision - mission statement / focus / population *
School / Organization Full Address School / Organization Full Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of Event / Title of Presentation *
Date of Event Date of Event * / MM / DD YYYY
Start Time of Event Start Time of Event * : HH MM AM/PM
End time of Event End time of Event : HH MM AM/PM
The presentation can be delivered ONLINE or IN PERSON (spaces may be limited) *

The presentation can be delivered ONLINE or IN PERSON (spaces may be limited) ONLINE IN PERSON
Number of Participants attending
(Our Preferred Size is maximum of 20 for Online and 30 for In-person) *
Who is attending the workshop? *

Who is attending the workshop? Teachers Administrators Professional Support Workers Community Staff Other Other
IN PERSON: Description of Venue (Preferred chairs in a circle, possibly the Library, or Meeting room with enough space for some movement activities)
We also require a PowerPoint projector with sound capability. Our facilitator will supplly a laptop with HDMI connector. If this is not available, please let us know.
Contact Person Name *
Contact Person Email address *
Organization website *
Bus Tel: with extension *
Cell phone Cell phone * - ### - ### ####