Form

200 RYT Teacher Training & Yoga Immersion Application

First Name*

Last Name*

Email Address*

Date of Birth*

- Month - Day Year

at

/ Hour Minutes

Address*

City/State/Zip*

Home Phone*

Mobile Phone

Emergency Contact Name*

Emergency Contact Phone Number*

Which Program are you applying for?

Full Teacher Certification (sessions 1 & 2) Full Yoga Immersion (sessions 1 & 2) Teacher Training Session 1 ONLY Teacher Training Session 2 ONLY Yoga Immersion Session 1 ONLY Yoga Immersion Session 2 ONLY

If registering for individual module(s) only, please indicate which modules you plan to attend.

How long have you been practicing yoga*

less than 6 months 6 months - 2 years 2-5 years more than 5 years

What is the primary style of yoga you practice?*

How often do you practice?*

less than once a week 1-2 times per week 3-4 times per week 5 or more times per week

Do you currently teach yoga?*

yes no

If yes, where? since when? what style? how many classes/week? how many students average per class?

Why do you want to participate in this program?*

What are your expectations of this program? What do you want to learn?*

Why did you start practicing yoga? Why do you continue to practice? What does yoga mean to you?*

Please list any physical or mental health issues (past or present) that instructors of this program need to be aware of.*

How did you hear about this program?*

LIABILITY WAIVER

In consideration and as an inducement of participating in programming provided by Transformation Yoga & Fitness and TeriLeigh Schmidt (including by not limited to: yoga instruction, spiritual retreats, aura and chakra readings, energetic healing instruction, and other services & training) I agree to the following: I have been examined by a licensed physician within the past six months and have been found by such a physician to be in good health and fully able to perform all exercises (yoga & other) which I am to learn and perform during this program. I will faithfully follow all instructions given to me by TeriLeigh and/or TYF instructors as to when, where, and how to perform and not to perform exercises (yoga & other), it being understood that any deviation by me from such instructions shall be at my own risk. I will not hold TeriLeigh Schmidt or TYF instructors or the hosting facility or location responsible for any injuries suffered by me caused whole of or in part by my failure to faithfully follow the instructions or by any physical impairment of mine not fully disclosed in writing. I understand and acknowledge that I am to receive instruction in yoga theory, healing techniques, and lifestyle philosophy as prescribed by TeriLeigh Schmidt or TYF instructors. I will not hold TeriLeigh or Elizabeth to any higher standard of care than applicable. I understand that TeriLeigh Schmidt is not licensed or certified in nutrition counseling and that this program is NOT a program to counsel me in specific food choices, but is instead a program focusing on mindful eating habits and yoga philosophy.I commit to completion of this course in full. I agree that the course fee paid hereafter is non-refundable. I agree to the cancellation policies outlined in registration documentation for retreats, workshops, and special events. By signing this form, I hereby release TeriLeigh Schmidt and TYF from any liability for injuries or health issues that are not directly and proximately caused by professional negligence. I understand that TeriLeigh Schmidt and TYF instructors are not credentialed to practice medicine, chiropractic, osteopathy, nursing, physical therapy, dietetics or nutrition practice, or acupuncture practice. I understand that TeriLeigh and/or TYF Instructors may provide me with personal consultations, screenings, assessments, an explanation of my health problems based on her method of detection regarding the complementary and alternative health care practice to be used. I understand that these actions do NOT constitute a diagnosis from a licensed physician, chiropractor, or acupuncture physician. I may seek services from a physician, chiropractor, nurse, osteopath, physical therapist, dietitian, nutritionist, acupuncturist, or any other type of health care provided at any time I see necessary. I agree to be added to TeriLeigh’s and TYF’s e-mail newsletter mailing list. If I do not wish to be added to the mailing list, I will not include my email address on this document.

By entering my initials here, I attest that I have read, understand, and agree to the terms listed in the Liability Waiver.*

PAYMENT & CANCELLATION POLICY

$500 deposit is required at time of application. Payment in full is due on May 1, 2010 for session one, and September 1, 2010 for session two. If you must cancel, written notification must be received by TeriLeigh LLC or TYF 15 days prior to the start of the session. Refunds for cancellations (less $100 processing fee) will be processed within 30 days of receipt of cancellation request. Cancellations received within the first two weeks of programming will forfeit $500 deposit. Cancellations received two weeks after the start of programming and thereafter will receive no refund. Injury and illness do not disqualify you from any of the above cancellation policies. We are unable to transfer deposits. We reserve the right to cancel with inadequate participant registration, in which case all money paid to will be refunded in full. TeriLeigh LLC, TeriLeigh Schmidt, and Transformation Yoga & Fitness cannot be responsible for any personal expenses such as airline tickets or lodging deposits due to changes in itineraries or tour cancellations.

By entering my initials here, I attest that I have read, understand, and agree to the above payment & cancellation policy.*

TEACHER CERTIFICATION ABSENTEE POLICY

Attendance and completion of all 200 hours of the Teacher Certification Program is compulsory and necessary for certification. If, in the event of an emergency I am not able to participate in any part of the program, I will be required to make up the time missed by scheduling a private class with one of the principal teachers (TeriLeigh Schmidt or Patrick Harrington) at $100 per hour. If I miss more than three workshops, I will not be allowed to finish the training; I will not receive a certificate, and I will not receive a refund of any money paid.

By entering my initials here, I attest that I have read, understand, and agree to the above Absentee Policy*

Please include a digital photograph (for identification purposes)*