Chi-Town Shakti

*First Name

*Last Name

*Email

*Street Address

*City

*State

*Postal Code

Home Phone

Mobile Phone

*Do you plan to work during your training? What will those hours be?

*How long have you been practicing Yoga? Please descibe your practice. Style, frequencey, etc.

*How long or have you been practicing Meditation? Please descibe your practice. Style, frequencey, etc.

*What are your personnal/professional goals for this teacher training?

*Do you have any physical injuries or limitations that might restrict our practice? If yes, please describe.

*Please list any surgeries or injuries in the past five years.

*Please list all current medications.

*Please list any diagnosed mental or emotional conditions:
This form is confidential.

*Please provide an emergencey contact and phone number:

*Occupation?

Payment Plan No, Thank you Yes

*Applying for? Level 1 Starting September 25 Level 3 Intermediate Starting September 6

If you are registering for a continuing education course where did you receive your 200 Hour certification?

Do you have any questions or other information you would like to provide?

How did you hear about the program?

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