100HR Restorative Yoga & Nervous System Rewire TTC Application

Full Name*

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Date of Birth*

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Email*
example@example.com
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EMERGENCY CONTACT DETAILS
Name*

PrefixFirst NameLast Name
Relationship to this person*
Phone Number*

Area CodePhone Number
Email*
example@example.com
How do you heard about this training? Please tick below:*

The Yoga Barn Poster or PostcardThe Yoga Barn WebsiteThe Yoga Barn NewsletterYoga Barn Class with TinaYoga Barn Workshop with TinaBalispirit.com WebsiteBalispirit.com NewsletterHELD WebsiteHELD NewsletterSchool of Sacred Arts (SOSA)Yoga JournalFacebookInstagramReferralOther
If referral, by whom?*
Yoga Experience
How long have you been practicing yoga and how often do you practice? What yoga styles or lineages have you explored? *
What style/s of yoga do you currently practice? (Share a few details about your current practice: consistency, duration, motivation, benefits etc.)*
Do you have a regular meditation practice? If yes, for how long and how frequent?*
From your perspective, what is Yoga & how does/can it benefit you & others?*
Via your direct experience, how does yoga serve your physical, emotional & mental health? And how does yoga asana translate as a spiritual practice? *
What are your primary motivations for attending this teacher training? What would you like to achieve from the training?*
This training is an immersion into ideas and concepts that require thought and reflection. Students who do not have a consistent asana and meditation practice should commit to a regular practice from now leading to the training. If at all possible, students should attempt to attend as many yoga & meditation classes as possible in their community before the commencement of the training, & read all pre requisite reading material (outlined in welcome letter upon registration)
- The 100hr Restorative Yoga & Nervous System Rewire Training is designed for yoga teachers with a 200hr RYT certification.
- Non certified Yogi’s may participate in the 100hr training if they have a minimum of 2 years yoga & meditation experience.
Yoga Teaching Experience
Are you a certified Yoga Teacher? If so at what level of accreditation? (Please list the schools you have trained with, including dates of education)*
Please list any additional previous yoga/meditation trainings/workshops/retreats experiences below:*
Are you currently teaching yoga &/or meditation? ( If yes, share some details about your teaching practice i.e. style, student demographics, open classes, private tuition, retreats etc.)*
How long have you been teaching yoga?*
What do you think makes a good yoga teacher?*
What do you think makes a good yoga student?*
Please express why you are interested in Restorative Yoga & Nervous System Regulation specifically?*
Medical Declaration
We require you to complete this Medical Declaration form due to the physical and emotional nature of yoga and related activities, if you fail to complete this declaration, you will be unable to attend the Training.

The information you provide in this Medical Declaration confirms that you are in good health and that there are no medical reasons why you should not partake in a Trauma-Informed Yoga Training.

The information provided will be treated with the strictest of confidence and will only be available to those who will be delivering Training activities to you. We will not share the information contained within with any other person except with your express consent. For legal and insurance purposes we will retain this information for a period of 3 years from the end of the Training, and this information will be stored securely.

Pease note, this information is vital & mandatory.

Providing accurate information here assists us in ensuring you remain protected, healthy and as safe as possible.

If you are currently under medical supervision for any reason, or have recently suffered an injury, operation, are pregnant, or have ever been under hospitalized psychiatric care, you must provide a doctors letter or certificate confirming that your medical representative permisses you to take part in the Training.
Doctors Email*
example@example.com
Are you currently in the care of a medical or natural healthcare practitioner? If yes, please describe:*
Please list any previous mental health history, including treatment/medication for conditions such as depression, anxiety, panic attacks etc:*
Have you ever experienced or been diagnosed with any of the following conditions?(Please check all that apply)*

ADHDAllergiesArthritisAsthmaAnxietyAnemiaAutoimmuneBack ProblemsBi-PolarBorderline Personality DisorderBroken BonesCancerCarpal Tunnel SyndromeCrampsChronic FatigueC-PTSDDepressionDetached RetinaDiabetesDissabilityEpilepsyFracturesHeadachesHearing DisorderHeart ProblemHigh Blood PressureHyperthyroidKnee ProblemLow Blood Pressure/FaintingMental Health DisorderMiscarriageNeck ProblemOperationsOsteoporosisPanic AttacksPersonality DisorderPTSDPsychosisPregnancySeizureSprainsStrokeStressSuicide AttemptedSuicidal ThoughtsVertigoVisual ImpairmentThrombosisUlcersNoneOther
If you checked any of the conditions above, please give details of when, duration and current status of the condition:*
Have you ever had injuries, or experienced any problems or damage to your: (Please check all that apply)*

ArmsAnklesCoccyxHeadHipsJointsKneesNeckSpineShouldersSacrumTendonsWristsNoneOther
If you checked any of the conditions above, please give details of your experience and current status of the condition:*
If you are currently under a prescription for any medications, inhalers or homeopathic treatments, please describe the prescription, dose and reason:
If you have had any operations (including birth or abortion) please provide details below, including when and outcome of surgery:
If you are currently using any recreational drugs, or substances including tobacco/cigarettes, please describe them and the frequency of use:
Do you have any current medical or physical condition that may affect your participation in this teacher training? If so, please indicate the condition thoroughly below:
Do you have any current physical, mental, or emotional challenges that could possibly be an issue during the course? (It is important that we are fully informed of such challenges prior to the training). Please be thorough & list in detail:
Please provide a short history of your past traumas, including the age when it occurred, e.g. 0 yrs mother smoked while pregnant, 0 - 3 yrs parents left me alone to cry, 5 yrs, family home burned down, 12 yrs fell off trampoline and broke arm, 26 yrs date rape at college, 34 years divorce and left abusive marriage:
I take full responsibility for my health during the Training. I will inform you of any medical changes. I understand that the Training includes physical movements, and that as is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that the instructions given throughout the sessions are intended as guidance only. I understand that while all due care will be taken by the teacher, they cannot be held responsible for my improper practice at any time. To ensure that no personal injury occurs, I agree to adjust my practice according to my limitations and the decision to perform any yoga postures remains mine. I declare that I will take full responsibility for myself during the Training*

I agree
I agree that I will email you regarding any new medical issues that arise prior to the Training commencement date and after completion of this Medical Declaration.*

I agree
I confirm that all information provided above is correct and up to date to the best of my knowledge.*

I agree
REGISTRATION
- $500.00 USD non-refundable desposit paid upon registration.
- Final payment is due upon acceptance to the training.
- Rates are listed in USD.
- Rates include tuition and programme manual.
- Rates do not include flight, accommodation, visa, meals and transportation in Ubud, Bali.
INVESTMENT:
- Standard Price : $2075 USD
- Early Bird Price : $1975 USD
- $1,875 U.S.D. each per module for 3x HELD 100hr modules for HELD 300hr Advanced Yoga Teacher Programme.
DEPOSIT:
- $500 U.S.D. non-refundable deposit payable upon registration
- Balance Payment Due – Upon acceptance to the training.
REFUND POLICY:
- The deposit is non-refundable and non-transferable.
- The deposit will only be refunded if the application is not accepted to the program.
- Tuition less deposit will be refunded in full 3 months ++ out from training commencement.
- 50% tuition (less deposit) will be refunded 6 weeks - 3 months out from the training.
- No refunds will be made within 6 weeks of the training
HEALTH & SAFETY POLICY:
- If the government restricts or shuts down group events in Bali - the training will be postponed to a later date once restrictions are lifted. If you cannot attend this date you have the option to transfer your payment to another future HELD training in person or online. You also have the option to transfer your spot to a friend.
- In the case you make your own decision and choose not to go forward with your travels, then the same policy and options as above will be applied.
Commitment:

In submitting this application form,
- You understand that the training can be taken as a self paced immersion.
- If desiring certification all training hours must be attended, and you agree to commit to 100% class attendance during the training, without exception.
- You agree to be 100% punctual & arrive to class 5-10mins before each lecture/practice, to arrive, settle & ground before each class begins.
- You agree to conduct yourself in a respectful manner towards your teachers, your fellow classmates and the studio staff.
- In the case of an emergency or significant illness, assignments will be set for hours missed to complete certification requirements
- You must speak, read & write English fluently
- You agree to abide by the payment policy : $500 non-refundable deposit paid upon initial registration, closing date for full payment is 1 month prior to commencement of training.
- You have read and understood that you are attending this course as an intensive immersion, & as such, you will devote your time and energies to give full priority to this training, practicing self-responsibility, ownership of your emotions, thoughts, and actions, consistent engagement in self-study and self-awareness, and open contribution to the overall group experience.
- You understand that you are required to fulfill the above obligations, to the satisfaction of the director and staff, in order to remain on the course, and that tuition payment alone does not guarantee certification from HELD. Punctuality, full participation, completing assessments & acting in a respectful manner of integral conduct will insure certification & successful completion of the training.
I understand that:*

$500.00 USD Deposit is non-refundable and non-transferable.Final payments are due upon acceptance to the training.Refund given ONLY in the unlikely event the training is canceled by HELD prior to programme commencement.
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I declare that all of the information provided above is correct and legally bindin
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REGISTRATION

INVESTMENT:

DEPOSIT:

REFUND POLICY:

HEALTH & SAFETY POLICY:

Commitment: