Kundalini Yoga Teacher Training Registration Form

7 Centers Yoga Arts Kundalini Yoga Teacher Training Registration Form

Please print this form and forward it along with your payment to:

7 Centers Yoga Arts, 2115 Mountain Road, Sedona, AZ. 86336 or email to: yoga@7centers.com

Name: _______________________________________________________

Date, Time and Place of Birth: _______________________ Sex: _______ Age: ______

Marital Status: _______________ Height: __________ Weight: ________

Street Address, State & Zip Code: ______________________________________________________________________________________

Telephone: _____________________________ Email: _________________________________

*We will be sending you an orientation letter - let us know if you need it mailed to a particular address. Otherwise we will contact you by e-mail.

Credit Card #: (Visa/Mastercard) : _______________________________ Exp. Date: ____________

Signature code on the back of your card: __________

Signature: _________________________________

If you are paying by check please make it payable to Mystis, Inc., our non-profit organization.

PAYMENT DETAILS

____ I am enclosing a deposit of $500 to reserve my space. (Balance due June 29th, 2012).

____ I am enclosing Early Registration (due before June 28th, 2012) payment in full of $3,295.00. Make check payable to Mystis, Inc

____ I am enclosing payment in full of $3,500.00 if registered after June 28th, 2012. Make check payable to Mystis, Inc.

____ Please charge my credit card below for the above amount:

Note: A deposit of $500 reserves your place. You may pay by cash, check or by

credit card. Once you are accepted for the course, the deposit becomes non-

refundable. The full fee is due 30 days before the start of the course and once the

course starts, there is no refund. In case of an emergency, you may apply the fee to

another course within one year of refund. The fee is not transferrable to another person. The course has a limited number of participants, so please reserve early.

I have read, understand & fully accept the tuition refund policy.

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Will you need housing arrangements? Yes___ No___

Will you need transportation? Yes___ No___

What is your primary reason for doing this teacher training? Do you intend to teach and/or do you want to deepen your personal practice? What do you hope to gain from this training?

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PRESENT OCCUPATION

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YOGA EXPERIENCE

Where & when did you receive your 200 hour Certification?

Was the teacher training Yoga Alliance registered? _____Yes _____ No

Have you studied Kundalini Yoga before? ___ Yes ___ No

What is your experience and who are/were your teachers?

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It is required that you be drug free, both prescription and recreational, caffeine free, nicotine free and alcohol free at least 2 months before the training. Can you attest that you qualify or will qualify by the start date of the training?

__________________________________________________________________________

Has any event (s) occurred in your life in the last 2 years that you would regard as stressful, challenging or even traumatic?

__________________________________________________________________________

Who can we call in case of an emergency:____________________________________

Telephone: ___________________________

How did you hear about us?

__________________________________________________________________________

"I understand that the Kundalini Yoga Teacher Training is a Yoga Intensive and may, therefore, offer elements that challenge me mentally, emotionally and physically. As a person seeking such an experience, I certify that I am in good physical, psychological and emotional health. I am ready, willing and able to explore the physical and subtle bodies including the five Koshas, the Chakras and Kundalini."

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