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:

*What is your occupation?

*WIll you require a payment plan? No, Thank you Yes

*Which Course are you applying for? Level 1 Three Month Starting June 1 Level 1 Six Month Starting March 6 Level 2 Intermediate Starting April 12 Prenatal Teacher Training Starting May 10

If you are registering for a continuing education course such as Intermediate Levels 2 or 3 or an elective 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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