Form

200 Hour Certified Yoga Teacher

First Name*

Last Name*

Email Address*

Date of Birth*

- Month - Day Year

Address*

City/State/Zip*

Country*

Phone*

Phone 2

Emergency Contact Name*

Emergency Contact Phone Number*

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 Inspiring Actions 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 IA 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 IA 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 IA instructors. I will not hold TeriLeigh or other instructors to any higher standard of care than applicable. 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 IA from any liability for injuries or health issues that are not directly and proximately caused by professional negligence. I understand that TeriLeigh Schmidt and IA 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 IA 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 IA’s e-mail newsletter mailing list. If I do not wish to be added to the mailing list, I understand I may unsubscribe at any time using the unsubscribe button on all emails.

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

$100 deposit is required at time of application. Payment in full is due for the full Teacher Certification Program on the first day of each session for individual modules. If you must cancel, written notification must be received by TeriLeigh LLC or Inspiring Actions 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. The application fee of $100.00 is nonrefundable except in the case of denial acceptance.The student will receive a full refund if they cancel within three business days before classes begin. The student, who withdraws after beginning instruction, but prior to 60% of course completion,shall receive a pro-rated refund based upon program length.No refunds will be made after 60% of the program is complete. Students will receive their refund within 40 days after dismissal or notification or withdrawal.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 will be refunded in full. TeriLeigh LLC, TeriLeigh Schmidt, and Inspiring Actions LLC 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 TeriLeigh Schmidt at $50 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*

RECOMMENDATION – A recommendation from a yoga professional attesting to your commitment to practice, personal character, physical ability, motivation, and integrity must be submitted to TeriLeigh LLC prior to acceptance of the program. PROOF OF PRACTICE – Proof of one year of consistent practice in the form of attendance logs at a home studio, reference letter from a yoga instructor, or personal journal of yoga practice must be submitted to TeriLeigh LLC prior to acceptance of the program.

PHOTO - for identification purposes, please include a digital headshot photo

Inspiring Actions - Application