URMC / Family Medicine / Mindful Practice / Curricula and Instructional Materials / Student and Resident Programs / Registration Payment Form Mindful Practice Program Online Payment Form *Chapin Mill Retreat Center - COVID-19 Vaccination - Attestation Required: I understand that the event location (Chapin Mill Retreat Center) will not permit entry to any attendee who is not fully vaccinated (~a minimum of two weeks post final vaccination shot). I understand and agree to provide proof of vaccination either prior to, or the day of the event. I understand that no refund will be given if I do not satisfy this requirement and acknowledge that the University of Rochester is relying upon my representation that I am fully vaccinated. First name Last name Email Address Verify Email Address Age Range 20-39 30-39 40-49 50-59 60-69 70 & older Gender Male Female Other Prefer not to disclose Profession -- please select -- MD DO PHD RN SW PA NP Other Other Profession ← to enter value select 'Other' Institutional Affiliation -- please select -- Medical school Hospital Group practice Private practice Other Other Institutional Affiliation ← to enter value select 'Other' Name of Institutional Affiliation Mobile Number What leadership role(s) do you currently have in your work setting? Hospital leadershipMedical/nursing school leadershipTraining program (e.g., residency, fellowship, advanced practice)LeadershipClinical team leadershipResearch program leadershipOther Other Leadership Role Where did you learn about this Workshop? ColleaguePrior AttendeeMindful Practice in Medicine WebsiteMindful Practice in Medicine Newsletter or Promotional EmailArnold P. Gold FoundationCentrum voor Mindfulness (Netherlands)Ad from another InstitutionOther Other source Check if you are Student/Resident Are you a student/resident at URMC? Check if you are registering with a group of 4 or more or you were referred from the Gold Foundation or Centrum voor Mindfulness (Netherlands) Check if we provided you with a special registration code Introductory Workshop - online only An Introduction to Mindful Practice in Medicine: Flourishing in Clinical Care Introductory workshop- Nov, 9th, 2024 – (7:00PM - 10:30PM ~ EDT)$175.00 per . Number of s = -- select --11/9/2024 $175.00 $0.00 Introductory workshop – Oct 1st, 2024 (5:30PM - 9:00PM ~ EDT)$175.00 per . Number of s = -- select --10/1/2024 $175.00 $0.00 Total: $0.00