RUMi Yoga Training Program Certificate Form

First Name

Middle Name

Last Name

Address 1

City

State/Province:

ZipCode

Country

Phone

Work Phone

Fax Phone

Occupation

Email:

Date of Birth

Gender :

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 :

How would you rate your overall healt :

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:

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?

Have you ever been convicted or placed on probation for any crime or offense, either felony or misdemeanor, by any federal or state jurisdiction?

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?