Radiant Wellness Yoga Therapy
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Integrative Yoga Therapy Teacher Training
200 Hour Application Form
Please complete fully and attach all required documentation.
Tuition is $2,595.00 US. A $300.00 deposit holds your place in the training.
Radiant Wellness Yoga Therapy
1183 Salt Marsh Circle
Ponte Vedra Beach, FL 32082
(904)280-4628
PLEASE COMPLETE ALL FIELDS WITH THE RED ASTERISK
if the question does not apply, please type "N/A" in the box.
If a field is left empty the form will not send.
Thank You.
We’d love to have a photo of you before you arrive. It is for reference only and is not considered in the screening process.
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Name
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First
Last
Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Date of Birth
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Current Occupation (if not currently employed, your vocation training or profession).
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How did you find out about Integrative Yoga Teacher Training?
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What would you like to most gain from the teacher training?
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What is your personal intention for taking the training program and how do you imagine that it will impact your life personally, professionally, socially, and emotionally?
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How long have you been practicing hatha yoga?
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How many times per week do you practice yoga?
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How long is your practice? (Choose One)
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½ hour
1 hour
1 ½ hour
2 hour
Which style (s) of yoga do you primarily practice?
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What does yoga mean to you?
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Are you currently taking classes with a certified teacher?
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Yes
No
What is your experience with other healing modalities?
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Yoga teacher experience
Are you currently teaching yoga?
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Yes
No
If yes, how long have you been teaching?
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What tradition / style?
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Number of classes per week:
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Why did you choose Integrative Yoga Therapy Teacher Training?
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Health Information
Describe your present State of health:
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Physical Limitation; chronic pain, disabilities?
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Yes
No
If yes, please describe:
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Serious illness, injury or major surgery within the last three years?
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Yes
No
If yes, please describe:
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Under medical treatment or supervision for:
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Yes
No
If yes, please describe:
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Current psychotherapy, counseling or psychiatric treatment:
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Yes
No
If yes, please describe:
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Hospitalization for psychiatric care within the last three years:
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Yes
No
If yes, please describe:
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Are you currently pregnant?
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Yes
No
If yes, please describe:
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Do you have a communicable disease?
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Yes
No
If yes, please describe:
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Are you recovering from an addiction?
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Yes
No
If yes how long have you been in recovery?
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List any prescription medications you are currently taking and indicate dosage and frequency of intake (we do not need to know about birth control or cosmetic prescriptions).
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Describe your weekly alcohol consumption.
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Please check and explain the following conditions that apply to you:
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Allergies
Arthritis
Asthma
Chronic Sinus Condition
Diabetes
Endocrine conditions
Epilepsy
Glaucoma
Hernia
Hypoglycemia
Heart Conditions
High Blood Pressure
Low Blood Pressure
Intestinal Conditions
Osteoporosis
Recent Injuries
Spinal Conditions
Ulcers
Urinary conditions
Comment
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Women Only:
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menstrual conditions:
PMS Symptoms:
Pregnant (due dates):
Hysterectomy:
Menopause symptoms:
Please describe any other physical or mental conditions that would be helpful for your instructor to be aware of. List any medications you are taking and the conditions you are taking them for.
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In case of emergency, please contact:
Name
*
Phone Number
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Physician
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Phone Number
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Therapist
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Phone Number
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I certify that the above information is true and complete to the best of my knowledge and that I will not hold Radiant Wellness Center Ltd, or my instructor liable for any mishaps arising from my participation in yoga teacher training.
By submitting this form I agree to abide by the
Teacher Training Program Policy and Agreement
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