New Online Registration Form Student Registration and Application Yoga Therapy Training Program Today's Date* Name* Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail* Enter Email Confirm Email Are you a Registered Yoga Teacher?* RYT 200 RYT 500 No *A 200-hour Yoga Alliance certification is required for participants seeking 500-hour certification with Yoga Alliance. A 200- hour yoga teacher certification is required for participants seeking 800-hour accreditation with IAYT-International Association of Yoga Therapists. A 200-hour yoga teaching certification is not a prerequisite for attendance for health professionals, body-workers, and/or holistic practitioners who are not seeking Yoga Alliance and/or IAYT accreditation.Where 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? Yes No Please elaborate What are your goals or expectations for this training? Where do you see yourself at the completion of the program? What particular skills and qualities do you bring to this 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? Yes No Who have been your primary yoga teachers?Do you practice meditation or Pranayama?Describe your studies and understanding of the yoga sutras, and any other of the classical texts of yoga. Provide the name and contact information of your current yoga teacher; and/or a certified yoga teacher who can give their recommendation of your readiness to participate in this training. What is your understanding of a yoga therapist and how does a yoga therapist differ from a yoga teacher? What do you feel are the most important qualities for a yoga therapist to embody? 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? Excellent Good Fair Some challennges (please describe) Do you suffer from any of the conditions below? Epilepsy Diabetes High Blood Pressure No, I do not suffer from the above conditions to the best of my knowledge Explain any past or present physical injuries that sometimes require yoga modifcations How is your current level of stress? Are you pregnant or do you plan to become pregnant during the course of training? Yes No Are 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 ContactName Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePrimary Physician (if any)Name Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneAdditional Information:Allergies Special needs or dietary restrictions Waiver 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:Program Tuition 300 hour programs ($4,500.00) 100 hour programs ($1,500.00) Online Courses Fee will be added soon!Deposit* Price: $750.00 Which program/location are you registering for?Choose a locationAustin, TX (Session Dates: Oct 1-16, 2016 and Feb 21-March 9, 2017)Colorado Springs (Session Dates: one weekend per month (Fri-Sun) over the course of 10 months, beginning Feb 2017 and completing Nov 2017)Chicago (Session Dates: one weekend per month (Fri-Sun) over the course of 10 months, beginning Sept 24, 2016 and completing June 10, 2017)Total $0.00 (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.