Name:

Mailing Address:

City:

State:

Zip:

email address:

circle which phone number you want me to call first.

Day Telephone number:

Evening Telephone number:

Cell phone:

Age:

Birthday: (we sometimes have cake)

Occupation:

1. On a separate sheet of paper: Please write a handwritten statement of intention. Why are you taking this training? What is the most important reason for taking this training? Please spend some time incubating this and be as specific as you can. I like this statement of intention handwritten because pen and ink convey so much feeling and more information than a computer. It is okay if your handwriting isn't prefect. In this training, you absolutely do not have to be perfect.

2.What best summarizes your intention? (pick only one)
a) I am mostly wanting this training to deepen my yoga practice.
b) I am wanting to deepen my yoga practice and I might want to teach yoga.
c) I definitely want to teach yoga part time.
d) I want to teach yoga full time.

3. Do you wish to only take the 100 hour Vinyasa Teacher Training?

4. Do you want to take the Certification program? Why?

5. How is your physical health? Please describe details, add extra pages if necessary. All inforamtion given is held in strict confidence.

6. Are you on any medications? Please describe details.

7. Have you had any surgery or medical procedures in the last 7 years? Please describe details.

8. Have you been in psychotherapy? Please describe for how long, for what condition and what insights you may have gained.

9.Please give me some idea of your family background. How would you characterize your relationship with your parents? (If they have passed away, please describe how your relationship was.)

10. Commitment Statement

I, ______________________________, understand that this Vinyasa Yoga Teacher Training is intellectually challenging and in order to get the most out of this training it will require many hours of reading, studying and pondering the philosophical insights of the Yogic Tradition. I am committing my full attention to this work for the next few months (to May 7, 2006, the end of Part One.)

__________________________________

11. Emergency contact person:

Their phone number:

Their relationship to you:

Eyes of the World

Box 2450

Providence, RI 02906

*your $100 nonrefundable check will be refunded if you are not accepted into the program. It is an initial statement of commitment that you are going to follow through and take this training if accepted.