200 Hour Yoga Teacher Training Program Application

yogaspirit® / Whitman Wellness Center

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Name:

Email:*

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Please indicate street address, city, state and zip.

Address*

Home Phone:*

Cell Phone*

Occupation/Vocation*

Date of Birth

Please list the training locations you are interested in.

Training Location(s):

How long have you been practicing Yoga? Please describe your background in yoga studies (teacher’s names, Yoga styles, etc.)

Yoga Practice*

Have you been taking regular classes for at least 6 months?

Personal Experience*

Do you have a daily Yoga practice? Please describe your practice. When did you start and how long do you practice each day?

Yoga & You*

Do you have a background teaching Yoga and / or other teaching experience?

Teaching Background*

Are you currently teaching Yoga? If so, number of classes per week? What traditions, styles and for how long?

Current Teaching*

What does Yoga mean to you, and how has it affected your life?

What Does Yoga Mean to You?*

Why do you want to take this training? What are your expectations of it and how will you utilize your Certification?

Why are you applying?*

Are you certified in other areas?

Other Certifications*

In your opinion what does a Yoga teacher provide for his/her students? What would you like to be able to provide to your students as a Yoga teacher?

What does Yoga provide?*

How did you hear about us?*

If you selected yogaspirit Alumni or Other, please provide name or resource.

Other

HEALTH INFORMATION FORM & WAIVER

Are you currently under medical treatment or supervision? If yes, please describe.

Current Medical Treatment*

Chronic Physical Limitations/Physical challenges (e.g. vision, hearing, movement, high blood pressure, asthma, etc.) Please describe the nature and extent of limitation(s) if any:

Chronic Limitations*

Serious illness or surgery within the last five years (e.g. heart, cancer, diabetes, etc.) Condition and date(s):

Serious Illness*

Any other surgery/procedures:

Other Surgeries*

Prescription Medications*

If yes, please describe.

Drug or Alcohol Addictions*

Are you currently pregnant?*

If yes, number of months at start of program?

Have you ever been hospitalized for anxiety/panic attack, emotional/mental condition? If yes, please describe.

Hospitalization*

Emergency Contact Name*

Emergency Contact Phone#*

Emergency Contact Relationship*

Emergency Contact Address*

Physician's Name*

Physician's Phone#*

DECLARATION OF DISCLOSURE & 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 revocation of Certification. I have enrolled in a Teacher Training Program of physical activity including, but not limited to various yoga and meditation exercises offered by yogaspirit® Studios. I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in this exercise program. I release yogaspirit® from any liability now, or in the future, including but no limited to: heart attacks, muscle strains, pulls, tears and broken bones, shin splints, heat prostration, knee, lower back or foot injuries and any other illness, soreness or injury, however caused, occurring during or after my participation in this program.

I understand that I am entitled to no refunds, credits or adjustments resulting from my failure to complete the certification requirements or to uphold any of these conditions.

Please write your name to confirm your understanding of the Declaration of Disclosure and Acceptance of Terms.

Signature*

Today's Date*

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