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First Name
Middle Name
Last Name
Address 1
City
State/Province:
ZipCode
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Phone
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Occupation
Email:
Date of Birth
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-Year-
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Gender
:
-Select-
Male
Female
Other
Height (in ft & Inch)
Height (in cms)
Weight (pounds)
Weight (Kilos)
Eye Color
Emergency Contact Name
Emergency Telephone No
Emergency Contact Relationship
How would you rate your general level of fitness
:
-Select-
Excellent
Good
Fair
Poor
How would you rate your overall healt
:
-Select-
Excellent
Good
Fair
Poor
How long have you practised Rumi Yoga:
Which certified Rumi Yoga Academy schools/teachers have you studied under and how long for each?
How many times a week you practise Rumi Yoga?
Have you ever practiced Rumi Yoga for 30 continuous days:
-Select-
Yes
No
If Yes, how many times and where?
Have you ever practiced other methods of yoga, and if so which
If yes, how long and which one?
Are you certified to teach other methods of yoga, and if so which?
What other exercise/sports do you practice and how often?
Are you able to study and memorize written material?
-Select-
Yes
No
Have you ever been convicted or placed on probation for any crime or offense, either felony or misdemeanor, by any federal or state jurisdiction?
-Select-
Yes
No
If yes, list each separate offense by date of conviction, offense, court of jurisdiction, and disposition (amount fined, term of probation, jail or prison, date released)
Do you currently use alcohol? If yes, how often
List any medical conditions you have and all medications, prescription and non-prescription, that you take
Why do you want to become a Rumi Yoga Certified Teacher?
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