Y4EDR Participant Application Form

Yoga for Eating Disorder Recovery

Participant Application

Thank you for your interest in joining our four-week online course, Yoga for Eating Disorder Recovery.

We use an application process to ensure the safety and well-being of all participants. Please read the following questions carefully. The entire application process should only take a few minutes.

Most applications are processed within 2-3 business days. Once approved, you will receive a link to complete registration via email.
About You

Personal Information
Name:*

First NameLast Name
Email:*
example@example.com
Date of birth:*

MonthDayYear
Please note, we are unable to offer the course to individuals under the age of 16
Phone Number:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about the course?*

Eat Breathe Thrive newsletterEat Breathe Thrive FacilitatorFacebookInstagramTwitterLinkedInOther social mediaFriend or loved oneReferred by professionalReferred by organizationInternet searchwww.eatbreathethrive.orgwww.givebackyoga.orgOnline event listingPrinted flyer or postcardNewspaper/magazine adOther
Please select all of the following that apply to you:*

Yoga professionalMental health professionalHealthcare professionalEducatorNutritionist / DieticianResearcherPeer MentorRecovery CoachCaregiverIn recovery from an eating disorderIn recovery from disordered eatingIn recovery from body image disturbancesRecovered or in sustained long-term recoveryNone of the above
Inclusivity Matters

The following section informs our efforts in ensuring diversity and inclusivity. Any information you provide may be stored and used in accordance with our Privacy Policy. For the purpose of confidentiality, any identifying information will be removed or changed before data is used in any way.
Please specify your gender or gender identity:*

Cis womanCis manTrans womanTrans manNon-binaryGenderqueerGender fluidAgenderOther
Please specify your sexual orientation:*

StraightGayLesbianBisexualAsexualQueerI’d prefer not to sayOther
Please specify your age:*
Please specify your ethnicity:*

Non-Hispanic White or Euro-AmericanBlack, Afro-Caribbean, African American, or African EuropeanLatino, Hispanic American, or Hispanic EuropeanEast Asian, Asian American, or Asian EuropeanSouth Asian, Indian American, or Indian EuropeanMiddle Eastern, Arab American, or Arab EuropeanNative American or Alaskan NativeI'd prefer not to sayOther
What is your household income? (Please answer in the most appropriate currency)*

Less than $15,000/yearLess than £15,000/yearLess than €15,000/year$15,000–$30,000/year£15,000–£30,000/year€15,000–€30,000/year$30,000–$50,000/year£30,000–£50,000/year€30,000–€50,000/year$50,000–$75,000/year£50,000–£75,000/year€50,000–€75,000/year$75,000–$100,000/year£75,000–£100,000/year€75,000–€100,000/yearOver $100,000/yearOver £100,000/yearOver €100,000/yearI’d prefer not to say
Your Health Matters
Are you in recovery from an eating disorder?*

YesNo
Please indicate below which eating disorder(s) you are in recovery from:

AnorexiaBulimiaBinge Eating DisorderEDNOS / OSFEDOther
Have engaged in self-harm behaviors (e.g. cutting or burning) within the past 30 days?*

YesNo
If so, please specify:
Have you attempted suicide in the past three months?*

YesNo
Have you had thoughts of suicide in the past month?*

YesNo
Eat Breathe Thrive Participation
Have you participated in any type of Eat Breathe Thrive course before?*

YesNo
Which events have you participated in?

Eat Breathe Thrive Seven-Week SeriesEat Breathe Thrive Three-Day ImmersionYoga for Eating Disorder RecoveryVirtual Campfire Social EventYoga + Recovery ChatsYoga & Eating Disorders: A Free Short CourseEating Disorders: How Yoga Teachers Can Help
If so, please specify:
How/where did you find out about this course?
Any information submitted with this form may be shared with your course facilitators, to optimize your experience and support your health & safety. Please indicate below whether you give your consent for the information herein to be shared with your course facilitators.*

I give my consent.I do not give my consent.
Participant Agreements

Please keep a copy of the agreements linked below for your records.
Name:*

First NameLast Name
Signature:*

Clear
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Should be Empty:

Yoga for Eating Disorder Recovery

Participant Application

About You

Personal Information

Inclusivity Matters

Your Health Matters

Eat Breathe Thrive Participation

Participant Agreements