PERSONAL INFORMATION:
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Contact Information:
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Name:
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Street address:
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City, State, Zip:
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Email address:
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Occupation:
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Home phone:
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Cell phone:
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Emergency
Contact Name:
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Phone:
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Relationship:
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Medical Information:
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1. List any prescribed medications you're taking or significant medical treatment you're currently undergoing:
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2. Is there anything we should know about your health, such as high or low blood pressure, diabetes or low
blood sugar, epilepsy, heart problems, depression or anxiety, neck, back, shoulder, wrist or knee injuries?
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Note on pregnancy: If you become pregnant after the start of the program, please let us know right away.
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Yoga History:
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1. Years/months of practice:
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Primary style of Yoga:
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2. Briefly describe a typical week's practice:
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3. Primary teacher(s). Please note their name, the style of yoga, the years/months you have studied with
them, and their contact information.
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4. Prior training(s), if any. (Please note the Name of the program, the Style of Yoga, the Length of training,
and Certification earned (if any):
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5. Teaching experience, if any. (Please note the Location, Begin (monthy/year), and End (month/year):
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6. Why are you interested in this program? What are your short and long-term goals?
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7. What is Yoga?
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FACULTY MEMBERS APPROVAL
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Please follow the steps below to apply:
- Please print the Faculty Members Approval form and have it completed by one of our faculty
members or by your primary teacher.
- Send a $25 non-refundable deposit by July 16th, 2007 to:
Piedmont Yoga Studio
ATTN: Advanced Training Manager
PO Box 11458
Oakland, CA 94611
- Click the Submit button below.
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