Teacher Training Online Registration Form Please fill out this form in order to register for the Yoga Teacher Training Program online. Make sure you answer all questions with as much detail as possible, where applicable. We'll be in touch with your shortly after your submission! Step 1 of 3 33% Form Download OptionIf you'd rather download the registration form and send it to us via snail mail, please click here: Download The Registration FormPersonal InformationName* First Name Last Name Date Of Birth*Date Of Birth Date Format: DD dash MM dash YYYY Mailing Address* Address Line 1 Address Line 2 City State State/ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number*Phone NumberEmail*Email Please list any injuries or limitations that you have that may affect your yoga practice? {i.e. back pain, arthritis, high blood pressure, etc.}*Please list any injuries or limitations that you have that may affect your yoga practice? (i.e. back pain, arthritis, high blood pressure, etc.)How did you hear about us?*How did you hear about us?AcknowledgementI acknowledge that there are inherent risks involved in the classes offered at Heart Space Yoga and Movement Center. I take full responsibility for my own safety while participating in classes and agree not to hold Heart Space Yoga and Movement Center or any of its teachers responsible for any injury or mishap that may occur while participating in programs at the center. Your Signature* First Name Last Name Date*Date of signature Date Format: DD dash MM dash YYYY About Your Yoga PracticeThis section covers your experiences with Yoga up to date. How long have you been practicing yoga?*How long have you been practicing yoga?How often and where do you practice now?*How often and where do you practice now?What styles of yoga have you studied? Where? With whom? For how long?*What styles of yoga have you studied? Where? With whom? For how long?What benefits have you experienced in practicing yoga?*What benefits have you experienced in practicing yoga?What physical activities do you presently engage in?*What physical activities do you presently engage in?Do you practice pranayama? If so, how often?*Do you practice pranayama? If so, how often?Every day2 to 3 times a weekOnce a week2 to 3 times a monthOnce a monthLess than once a monthI don't practice pranayamaDo you practice meditation? If so, how often?*Do you practice meditation? If so, how often?Every day2 to 3 times a weekOnce a week2 to 3 times a monthOnce a monthLess than once a monthI don't practice meditationHave you taken any yoga workshops or trainings in the last 3 years? If so, please include topics and teachers.*Have you taken any yoga workshops or trainings in the last 3 years? If so, please include topics and teachers.Do you teach yoga now? lf yes, for how long, what type of format, facility and style of yoga?*Do you teach yoga now? lf yes, for how long, what type of format, facility and style of yoga?Do you have any other type of teaching experience? Please explain.*Do you have any other type of teaching experience? Please explain.Are you interested in being certified and/or Yoga Alliance Registered?*Are you interested in being certified and/or Yoga Alliance Registered? Your HealthIn this section you can tell us a little more about your physical and mental health. We'd like to accommodate to any special needs you may have. Rest assured, this information stays safe with us. Tell us about your physical health and any limitations or special needs.*Tell us about your physical health and any limitations or special needs.Tell us about your mental and emotional health, (previous therapy, eating disorders, bouts of depression, addictive behavior, etc. Please note that any difficult times you have gone through will bring you closer to students experiencing the same).*Tell us about your mental and emotional health, (previous therapy, eating disorders, bouts of depression, addictive behavior, etc. Please note that any difficult times you have gone through will bring you closer to students experiencing the same).Tell us about your dietary health and any special needs.*Tell us about your dietary health and any special needs.What is your intention for attending this course?*What is your intention for attending this course?CAPTCHA
