Apply Online Personal Information First Name Last Name Street Address City State Zip Phone Email Let Us Know About Your Physical Health Date of Birth Sex MaleFemale Current Occupation Emergency Contact Phone Relationship Give us an assessment of your current physical health ChallengedFairGoodExcellent Are you currently, or during the last 2 years been, under the care of a physician/other health care professional? YesNo If yes, for what reason? Please list the health care professional's name, specialty, and address: Name Specialty Address Do you have epilepsy? YesNo Do you have diabetes?YesNo Please list any medications you are currently taking or have taken in the last year that were prescribed by a health care professional Are you currently, or during the last two years, have you been under the care or supervision of a mental health professional (psychiatrist, therapist, etc.)? YesNo If yes, for what condition? Please list the mental health professional's name, specialty, and address: Name Specialty Address Please list any medications you are currently taking that were prescribed by a mental health professional Have you been hospitalized in the last year? YesNo If yes, for what condition? Do you have any special dietary requirements? YesNo If yes, please list Do you have any challenges participating in any physical activities? YesNo If yes, please list Do you smoke? YesNo Do you drink alcohol? YesNo If yes, how much and how often? Do you use drugs? YesNo If yes, how much and how often? Additional Information Please describe your yoga background What yoga style do you practice? Why do you practice yoga? And how long have you been practicing? How often do you practice? Please list your most-influential teachers and styles. How often and for how long have you studied with them? Why do you want to become a yoga teacher? If you have chosen this training simply for personal growth and have no intention to teach, what do you hope to gain? What schooling or training have you had that would provide a useful background or would be an asset to you in your teacher training? (massage, medical/anatomical studies, teaching in other disciplines, university degress, etc.) If you teach now, tell us about your teaching history Do you have any pre-existing injuries that may affect your ability to participate in this course? What are your top two intentions for personal growth? In addition to your application please submit a digital photo to Julie and Heather at firstname.lastname@example.org Payment Requirements Upon submitting your application, you will be redirected to a page where you can make a deposit payment of $500. The remainder of payment must be received prior to the start of training. All monies are non-refundable and non-transferable. Payment can be made online via PayPal/credit card or by check.