Date of Birth
Do you have a degree? If so, what is the degree and in what field/discipline?
Do you have an Advanced degree? If so, what is the degree and in what field/discipline?
Please describe the setting in which you will be teaching mindful eating skills, and any experience you already have facilitating such skills.
Do you have a regular meditation practice? Please state the tradition, number of times a week you practice, length of each session, and number of years you have been practicing. Please describe in 50 words or less.
Please state your participation in teacher-led silent mindfulness meditation retreats of 3 days or more only. Include the following:
Beginning and ending dates of the retreat, Location
Alternately you may state your formal meditation training, stating the tradition, your teacher's name and the frequency and length of training.
(NOTE: MBI trainings do not qualify as mindfulness meditation retreats.)
Have you completed an 8-week MBSR, MBCT or ME-CL program as a participant? If so, state the program name, beginning and ending dates, location and teacher's name.
Do you have a mindful movement practice such as yoga, Tai chi or Qiqong? Please state the tradition, number of times a week you practice, the typical length of each session, and number of years you have been practicing. Please describe in 50 words or less.
Please explain why you want to take this ME-CL1 Training in 200 words or less.
Do you understand and agree to the terms and conditions stated above? Yes
Please attach your most current CV
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