APPLICATION FOR CHAKRA INTENSIVE TRAINING

ALL INFORMATION ON THIS FORM IS CONFIDENTIAL

BASIC INFORMATION

NAME ________________________________________________________DATE _________________

ADDRESS ______________________________________________CITY _________________________

STATE_________________________ ZIP_________________ COUNTRY_______________________

PHONE: HOME _____________________________ CELL ___________________________________

EMAIL ______________________________________________________________________________

BIRTH DAY _________________BIRTH TIME ____________ LOCATION _____________________

OCCUPATION _______________________________________________________________________

PROGRAM DATES __________________________

_____ I HAVE ENCLOSED PAYMENT OF $850 FOR THE COURSE (please initial)

Credit Card Number: __________________________________ Exp. Date: ____ / ____

or MAKE CHECKS PAYABLE TO: 7 CENTERS YOGA ARTS

PERSONAL INFORMATION 1. How did you hear about 7 Centers Yoga Arts and our program?

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2. What is the main reason for your interest in this program?

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3. List three things you hope to learn/accomplish from our training:

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APPLICATION FOR CHAKRA INTENSIVE TRAINING

4. What is your experience with Yoga? How long have you been practicing, where and with whom? What are the most rewarding and challenging aspects of your practice? _____________________________________________________________________________________________

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5. Please list any physical or mental health conditions that could impact your experience during the training?

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7. Please write a short bio including any other pert inent information here:

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PLEASE RETURN COMPLETED APPLICATION TO: 7 Centers Yoga Arts

2115 Mountain Rd, Sedona, Az 86336 You can email a copy to yoga@7centers.com

Email or Call 928-203-4400 with any Questions