Mindful Self-Compassion Registration and Consent Forms

MSC Online Registration and Consent Form

Your privacy will be respected. Personal data submitted on this Online Form will be deleted permanently after 24 hours. Your submissions will be emailed to the Instructor immediately. Responses are kept confidential and will only be shared with the instructor for the course and purged after being reviewed. You may be contacted for a brief phone interview before the course begins. You will be asked to sign an informed consent agreement so the instructor may record audio of themselves for training purposes.

Name * Required
First Last
Gender Identity
Ethnicity/Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Pacific Islander
- White
- Hispanic or Latino
- Other
Emergency Contact Person
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email * Required
Phone (best contact number) * Required
Emergency contact person * Required
Emergency Contact Phone * Required
1. What is your main reason for participating in the MSC Program? * Required
2. Occupation: * Required
3. Date of Birth * Required
MM slash DD slash YYYY
4. What do you care about most? * Required
5. What gives you the most pleasure in your life? * Required
6. What do you worry about? * Required
7. Please list three personal goals you have for taking the MSC Program: * Required
1. 2. 3.
8. How did you hear about this program? * Required
Consent Section
Email Communication Consent * Required
As a participant in the Mindful Self-Compassion Program, you may wish to communicate with your instructor via email on occasion. There are risks of any electronic communication, including that the message could be intercepted or delivered to the wrong recipient. By completing this registration form, you acknowledge that you understand and accept the risks associated with email correspondence.
Acknowledgment and Waiver of Liability * Required
I accept full responsibility for my health and voluntarily complete this Acknowledgement and Waiver of Liability. I understand and agree that the services and tools offered in the University of Arkansas for Medical Sciences Mindfulness Program offered by the teachers of the University of Arkansas for Medical Sciences Mindfulness, its officers, employees and agents are not intended to replace or be substituted for medical or psychiatric care. It is recognized that the trainings inherent in the programs may at times make participants feel vulnerable. Mindfulness programs are not therapeutic interventions for psycho-pathological disorders as defined in the DSM and are not intended as such. By completing this release and consent I assume all risk for any physical or mental consequences of participating in the program. By signing this release I also specifically and expressly agree to hold harmless, indemnify and release the teachers of the University of Arkansas for Medical Sciences Mindfulness Program, its officers, employees and agents from any and all liability for the results of the educational guidance that will be or have been provided. Moreover, I acknowledge that the particulars shared in these classes by other participants are to be maintained as confidential. I will not blog or otherwise report on content shared in these classes in any form of media.
Consent * Required
I agree and consent to the Agreements above, and I certify that this form is being completed by the registrant
Name
This field is for validation purposes and should be left unchanged.

MSC Online Registration and Consent Form

Consent Section