Online Registration Form Student Registration and Application Yoga Therapy Training Program Today's Date* Name*PrefixFirstLastSuffixAddress*Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryPhoneEmail*Enter EmailConfirm EmailAre you a Registered Yoga Teacher?*RYT 200RYT 500NoWhere did you receive your Yoga Teacher Training?SchoolLocationDate of Graduation How long have you been teaching yoga? (Describe in terms of years or hours)Where do you teach?What style of yoga do you teach?Are you a health care professional?YesNoPlease elaborateWhat are your goals or expectations for this training? Where do you see yourself at the completion of the program? More About YouHow many years have you been practicing yoga?How many days per week to you practice yoga?What style of yoga do you usually practice?Where do you currently practice?Do you have a home practice?YesNoWho have been your primary yoga teachers?Do you practice meditation or Pranayama?Is there anything else you'd like to share about yourself? Medical HistoryPlease complete the medical history section below so that we can be sure to respond to any emergencies should they occur during your training. Please note that none of your responses will exclude your from being accepted into the program.How would you evaluate your current health?ExcellentGoodFairSome challennges (please describe)Do you suffer from any of the conditions below?EpilepsyDiabetesHigh Blood PressureNo, I do not suffer from the above conditions to the best of my knowledgeExplain any past or present physical injuries that sometimes require yoga modifcationsHow is your current level of stress?Are you pregnant or do you plan to become pregnant during the course of training?YesNoAre you currently or during the last two years have you been under the care of a physician or mental health care professional?Please list medications you are taking prescribed by your physician or mental health care professional. Emergency Contact InformationRelative or ContactNameAddressStreet AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodePhonePrimary Physician (if any)NameAddressStreet AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodePhoneAdditional Information:AllergiesSpecial needs or dietary restrictionsWaiver of Liability:I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against my instructor or Inner Peace Yoga Therapy.Waiver of Liability*I understandFees & Accommodations:TuitionTuition300 hour programs100 hour programOnline coursesMentorship ProgramPay at a later DateDepositPrice: $750.00Which program/location are you registering for?Asheville, NC (Session I: May 7–20, 2014) (Session II: September 9–23, 2014)Mt. Madonna, Watsonville, CA (Session I: October 18–31, 2013) (Session II: March 4–17, 2014)Durango, Colorado (Session Dates: July 21-21, 2015)Just pay depositAccommodations (includes Meals ) please selectAccommodationsAsheville, North CarolinaCommuter (includes meals) DormPrivate room (if available)Mt. Madonna, Watsonville, CACommuter (includes meals)Own TentOwn VanCenter Tent DormTripleDoubleDouble w/ bathSingleSingle w/ bathDurango, ColoradoShared rooms (includes meals) Total Fees$0.00(Total of Tuition + Accommodations)(Your application will be reviewed within 30 days. Upon acceptance of your application, A $750 deposit will hold your space; the tuition balance is due 30 days prior to the start of the training; accommodations charges are due at the start of the session.) To register via email or mail, download this application and: Mail to: Inner Peace Yoga Therapy, PMB #411, 10 Town Plaza Durango CO 81301 USA or email: email@example.com Deposits are refundable until 30 days prior to the training start date, with a $100 administrative fee deduction. Please call (970) 946-8961 for more information.PhoneThis field is for validation purposes and should be left unchanged.