Stress Reduction - Registration Page

Employee Assistance Services
With you every step of the way.

Life Management Associates
1848 Charter Lane
Lancaster, PA  17601

info@LMA-EAP.com


Mindfulness Meditation Class

 

Online Registration - Complete form below and submit.
Phone Registration - 717.394.6688 / 800.327.7770

Please complete registration form.  All information is confidential.

I am registering for the following class location:

Lancaster - Mondays, October 5th - November 9th (3-4:00PM)
Harrisburg - Wednesdays, September 23rd - October 28th (7:30-8:30AM)

First Name
Middle Initial
Last Name
Street Address
City
State
Zip
Home Phone (with area code)
Work Phone (with area code)
Cell (with area code)
Email (class confirmation/changes will be made via email
Employer / School

Rates:  $15 per class
Individual Class - $15/class
Register for 6 Classes - $80
EAP Session: 6 classes (You may use one EAP session for six classes.)

** No refunds for unused classes **

Method of Payment:
- Cash (bring to class; receipt will be provided)
- Check (payable to Life Management Associates.  Please note in Memo:  Meditation/Class Date)
- Credit Card (to use your credit card, call LMA office at 394-6688)
- I will be using PayPal for payment (once you click the submit button at the end of this form, you will be forwarded to a confirmation page, when you can select PayPal option)
- EAP (1 EAP Session = 6 classes)

IF YOU ARE USING YOUR LMA EAP TO ATTEND, PLEASE COMPLETE THE FOLLOWING SECTIONS:
(if not using EAP sessions, click on the submit button at the bottom of this page)

Birthdate:
Gender:
Years Employed by Organization:

CHECK ONLY ONE IN EACH CATEGORY:

Referral Source

Self
Management (Mandatory)
Management (Suggested)
Union
Medical
Employer / Human Resources
Family
Co-Worker / Friend
Managed Care Program
Other / Unknown
Advertisement (please specify)

Education Completed

Young child (not yet in school)
Preschool / Kindergarten
Grade School
Some High School
High School Graduate
GED
Trade / Technical School
Some College
Associates Degree
Some Graduate School
Graduate Degree
Some Post Graduate
Post Graduate Degree

Marital/Relationship Status

Single
Married
Divorced
Separated
Widow / Widower
Cohabitating

Ethnic Origin

Black / African American
Hispanic
Asian / Pacific Islander
Native American
Caucasian
Other
Job Category
School Employees:
School Administration
School Middle Mgmt / Dept Head
School Teacher
School Salaried (other than teacher)
School Hourly
Other Employees:
Executive
Management
Supervisor / Line Leader
Professional
Technical
Administrative
Outside Sales
Skilled Labor / Craftsperson
Service
General Labor
Other / Unknown / NA

If you are a family member of an employee who has Employee Assistance Program (EAP) benefits, complete this section about the employee:

Name
Street Address
City
State
Zip
Home Phone
Work Phone
Date of Birth
Employer
Relationship to Employee:
Spouse
Child
Stepchild
Parent
Other
Marital Status
Single
Married
Divorced
Separated
Widowed
Cohabitating
Gender
Male
Female
Education Completed (check highest level completed)
Young child (not yet in school)
Preschool / Kindergarten
Grade School
Some High School
High School Graduate
GED
Trade / Technical School
Some College
Associates Degree
Some Graduate School
Graduate Degree
Some Post Graduate
Post Graduate Degree

 

 


Submit Your Registration - Thank you.