300 Vinyasa Application Submitted

First Name *
Last Name *

Email *

Phone *

Street Address 1 *
Street Address 2
City *
State *
Postal Code *
Country *

How did you hear about this training? *

What is your reason for taking this training? *

Yoga Background

In what year did you start practicing yoga? *

How many times do you practice each week? *

What tradition(s) or style(s) do you practice? *

Health Background

All responses are strictly confidential. We use this information only to better assist you during the program, not to screen participants, unless your doctor determines that participation would be medically inadvisable.

Please briefly describe your current overall health. *

Describe history (include dates) of back/spine/neck problems. *

Describe any history (include dates) of joint problems. *

Blood Pressure *

Date blood pressure was last checked *

Have you ever taken blood pressure medication? *

YesNo

Date last blood pressure medication was taken

Have you experienced any of the following? (Please use Ctrl to select multiple items) *

If any other not listed, please specify.

Describe any history or risk of cardiovascular disease. *

Any other limitations, dietary restrictions, or health issues? *

Any learning challenges or disabilities we can support you with? *

What are your current stresses and psychological challenges? *

Women: Are you pregnant?

YesNo

If pregnant, what is your due date?

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone *

Emergency Contact Email *