"Path to Empowerment"
200-Hour Yoga Alliance
 Teacher Certification
September 2010 - March 2011

APPLICATION FORM

CONTACT INFORMATION :

LAST NAME FIRST NAME

ADDRESS

CITY STATE ZIP

EMAIL ADDRESS
(We respect your privacy. We will never share your information to anyone or to any organization).

CELL PHONE HOME PHONE WORK PHONE

OTHER INFORMATION :

AGE

PROFESSION (generic, e.g. healthcare, legal, banking, etc.)

MARITAL STATUS

GENDER

PHYSICAL HEALTH

Under physician's care? Yes No
If yes, for what reason?

Epilepsy? Yes No

Diabetes? Yes No

Are you currently seeking mental health care? Yes No
If yes, for what condition?

Please list any current medications:

Do you have any dietary requirements?

What is your past history with yoga practice?

SETTING YOUR INTENTION

Please take a moment to write down what you want out of this intensive experience.
There is a power in writing down goals, sharing them and then referring to them often.
It is suggested that you do the above practice in preparation for this week. At the very least,
please share your goals for this experience with us now so we may better support you during the intensive.

Thank you for your application. Someone from our staff will be on contact with you within 7-10 days.