AnxietyAsthmaBack ConditionBi-Polar Disorder
High/Low Blood PressurePregnantPTSDOther
If you selected: Cancer (stage), Diabetes (type), Pregnancy (Due Date) or Other - please clarify below:
Previous yoga, yoga nidra and meditation experience and years:
Current certifications, licenses:
How did you hear about the training?
Why are you interested in this training?
Emergency contact (name and phone number)
I accept responsibility for my own health and safety. I relinquish meditation chick, all elements yoga and instructors from all liability. $500 non-refundable deposit is due to reserve my space. I understand and accept that early bird pricing of $1800 must be paid on/before June 27, 2018. After June 27, course fee is $2000. All course fees must be paid in full by September 10, 2018.
Signature (required) Date (required)