Niroga Yoga Teacher Training programs

2012 Certified Yoga Therapy Specialist Training Program Application (Level 3)

Application Information - bold fields are required * For any personal information that you wish to provide in a more secure format, please enter "Will provide offline" below, and follow up with that information by phone, fax, or hard copy with a reference to this application.
Name:
Street Address:
City:
State:
Zip Code
Primary Phone:
Home Phone:
Work Phone:
Cell Phone:
Email:
Occupation:
Date of Birth
Sex:
How did you hear about this program?

Emergency Contacts:
Name: Phone:
Name: Phone:
Physician: Phone:

Yoga Teaching and Yoga Therapy Experience:
How long have you practiced yoga? Describe your personal practice of yoga and how regularly you practice:
What styles/traditions of yoga have you practiced?
What style/tradition do you practice now?
Are you currently teaching yoga? If so, how often do you teach yoga?
What styles of yoga do you teach? How long have you been teaching?
Have you taken any yoga therapy training programs? If so, which one(s), and are you currently practicing yoga therapy?
Have you studied yoga philosophy?
Have you studied Ayurveda?

Motivation:
Why do you want to take this training program?
What are your goals and objectives for this course?
Do you have any special interests or capabilities that may be relevant?
How do you intend to use Yoga Therapy in your practice, both personally and professionally?

Health Information:
Current health:
Pregnant / How long:
Chronic physical limitation/disability:	Details:
Prescription medications and/or natural remedies (include condition)	Details:
Serious illness or major surgery in the last 5 years:	Details:
Communicable Diseases:	Details:
Current psychotherapy, counseling, or psychiatric treatment for Drug/alcohol addiction or Eating Disorder?	Details:

Payment Total Cost - $3,000.00 Fees include all classes, instruction, books, and materials. Payment Plan ~ $500.00 non refundable reservation fee due within 7 days of acceptance of application ~ $2,500.00 due by January 27, 2012 ~ Note: If you have been accepted into the program, your spot is not guaranteed until receipt of the reservation fee Refund Policy ~ The $500.00 reservation fee is non-refundable. ~ The $2,500.00 fee is fully refundable up to 5 days before the start of training. ~ Within 5 days of the start of training, there are no refunds. Disclosure and Acceptance of Terms By submitting this form I hereby declare the above information is true to the best of my knowledge. I understand that misrepresentation of this information constitutes grounds for the rejection of this application, expulsion from the program and revocation of certification. In the event of rejection, expulsion, or revocation of certification, I understand that I am entitled to no refunds, credits, or adjustments.

Niroga Yoga Teacher Training programs

2012 Certified Yoga Therapy Specialist Training Program Application (Level 3)

Yoga Teaching and Yoga Therapy Experience:

Motivation:

Health Information:

Payment