| Your Name: |
|
| Dates of Retreat / Training: |
|
| Address: |
|
| City: |
|
| State and Country: |
|
| Zip / Postal Code: |
|
| Cell Phone: |
|
| Work Phone: |
|
| Occupation: |
|
| Email Address: |
|
| Sex: |
Male
Female
|
| Date of Birth: |
|
| Regular Yoga Practice For One Year?
Yes
No
|
| Years Practicing Yoga: |
|
| Practiced with a Certified Yoga teacher
for at least 6 months? Yes
No
|
| Names of Yoga Teachers: |
|
| Yoga Styles/Traditions: |
|
Do you have a regular meditation
practice?
Yes
No
|
| Have you been on a meditation
retreat? Yes
No
|
Are you familier with the
Ashtanga Vinyasa Primary Series?
Yes
No
|
| How did you hear of this training / retreat? |
|
|
Please answer the following 2 questions in 1-2 short
paragraphs:
|
| Describe your personal practice: |
|
| Why do you want to take this training / attend this
retreat? |
|
|
Health Information:
This is a Required Field
|
| Current Health status: |
|
| Under medical treatment or supervision for: |
|
| Pregnant (how many months): |
|
| Injuries: |
|
| Chronic physical limitation / injury: |
|
| Prescription medications: |
|
| Physician Name & Phone Number |
|
| Emergency Contact Name & Phone Number |
|
| Once you
have been accepted into the training or retreat, you
will be given instructions on how to make your payment. |
| |
|
| For Teachers Training: Resident or Non Resident,
please indicate. |
|
|
Declaration of Disclosure and Acceptance of
Terms:
I hereby declare the above information is true
to the best of my knowledge. I understand that misrepresentation
of this information constitutes grounds for the
rejection of this application, expulsion from the
program or revocation of certification. I understand
that failure to complete the certification requirements
will result in my not being certified. I understand
that I am entitled to no refunds, credits
or adjustments resulting from my failure to attend,
complete the certification requirements or uphold
any of these conditions.
Greenpath Yoga Studio does not discriminate on
the basis of race, color, religion, national origin
gender, age, disability or sexual orientation. The
information contained in this application will be
treated confidentially.
www.Greenpathyoga.org
|
| Signature: |
|
| Todays Date: |
|
|
|
