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* 1. What is the name you want to be called?

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* 2. What is your email address?

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* 3. What is your phone number?

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* 5. What do you hope to get out of participating in this program?

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* 6. What is your experience with mindfulness meditation/practice?

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* 7. What, if any, access needs do you have to make your participation possible?

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* 11. All proceeds from this program will be donated to Youth on Their Own.  We will be accepting donations on a sliding scale, from $40-$200.  What amount would you like to donate?

40 200
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i We adjusted the number you entered based on the slider’s scale.

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* 12. Payment for this series needs to be received by February 8 to hold your spot.  How would you like to pay?  Please make your selection AND follow the instructions in the option of your choice.

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* 13. Is there anything you think we should know about you, or that you'd like to share with us?

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