Teacher Training Form First Name Last Name Street City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode Email Mobile Phone Home Phone Occupation Gender Male Female D.O.B. Marital Status Emergency Contact: Name Phone Relationship Do you currently practice yoga? Yes No If yes, where? Do you currently attend classes at Plymouth Yoga Room? Yes No Please list your previous yoga experience (length of time, types of yoga). Please List any NON-Yoga personal growth, transformational based courses, workshops, seminars or retreats you have completed. Why are you interested in the Yoga Immersion Program? What are your expectations from this program? What do you hope to gain,learn or work through? Are you willing to follow a strict regimine during the Immersion process? Yes No Do you have the support of your family? Yes No How is your current health? Excellent Good Fair Challenged Please detail your current health and health history. Please detail any other pertinent information not covered above.