Individual Registration

Please enter information in the form below to process registration for the program Mindfulness-Based Stress Reduction - Mountain View, Evening Class (Free Intro 5/21/20).

First Name *

Last Name *

Address *

City *

Zip *

State *

Phone *

Email *

Comment

Have you taken the Mindfulness-based Stress Reduction class at El Camino Hospital before? *

yes

Are you an El Camino Hospital employee?

yes

Payment Information

Scholarship Code

Amount

Scholarship Amount

Total

Payment Method

Visa/ MasterCard/ Discover/ Amex/ Paypal

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

By registering for this program, I accept Terms and Conditions

Individual Registration

Payment Information

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