Application

Ananda Yoga® Teacher Training FALL 2010

Please complete this form and the medical questionnaire, and mail to:

Ananda Yoga of Portland, 4855 SW Watson Ave, Beaverton, OR 97005

All responses are strictly confidential.

Name ______________________________________________________

Name you prefer to be called _________________

Address_____________________________________________________________

Phone: Home (_______) ________________________________

Work (_______________) Fax: (______________)

E-mail______________________________________________________

1. Deposit required to reserve your space: $400 (Please review the complete financial listed below)

Cash

Check. Please make out 2 checks. 1) Payable to Ananda for $300 and 2) payable to The Expanding Light for $100

Visa. MasterCard Card Number ___________________________________Exp. Date__________

Signature____________________________________________________________

2. How did you first find out about this training? (E.g., Internet search, ad in Yoga Journal, friend, etc.)

3. Please tell us your reasons for taking this training.

4. How long have you been practicing hatha yoga? Which tradition(s) or style(s)?

How many days per week do you practice, and for how long each day?

How many months/years have you been practicing.

Have you practiced Ananda Yoga? Yes / No

If so, how much?

If not, why have you chosen Ananda’s training?

5. Ananda takes a classical approach to Yoga: as a spiritual practice, the goal of which is Self-realization. Is this the approach you’re looking for in a yoga teacher training program? Yes / No

6. Do you practice meditation regularly? Yes / No

If yes, how often and how long do you practice?

7. Do you have any other information or concerns to share about attending this program? Use separate page.

8. I have a copy of The Art and Science of Raja Yoga (formerly 14 Steps to Higher Awareness). I’ll bring it with me.

I don’t have a copy. If I’m accepted into the program, please send it to me.

The cost is $24.95 plus $8 shipping (no P.O. boxes) within the U.S.; the $24.95 will be deducted from your balance due. Include this amount with your deposit, payable to Ananda.

I hereby certify that the above information is correct to the best of my knowledge and that I have read and agree to the financial terms and conditions listed on the back of this application.

DATE:

PARTICIPANT’S NAME:

PARTICIPANT’S SIGNATURE:

Medical Questionnaire

All responses are confidential. We use this information only to better assist you during the program, not to screen participants (unless participation would be medically inadvisable). Attach additional sheets if necessary.

Name ___________________________________________________________

Date of Birth _____________

1. Please briefly describe your current overall health.

2. Describe any history (include dates) of back/spine/neck problems, and indicate whether they still give you problems. Please be specific.

3. Describe any history (include dates) of joint problems (knee, hip, shoulder, etc.), including joint

repair/replacement surgeries. Please be specific.

4. Blood pressure (circle one): High / Low / Normal. When was it last checked? __________

Have you ever taken blood pressure medication? Yes / No. If so, how recently?_________

5. Describe any history (even if you are just "at risk") of cardiovascular problems.

6. Circle any of the following difficulties you have had and explain relevant specifics: Diabetes / Osteoporosis-Osteopenia / Chronic headaches / Ulcers / Stroke / Seizures / Allergies / Asthma / Cancer /

Frequent dizziness / Other

7. Women: Are you pregnant? Yes / No. If so, when is your baby due?

8. Do you have any other limitations, dietary restrictions, or health concerns? If so, please explain.

9. Are you currently seeing a physician or therapist for any physical or psychological conditions?

Yes / No. If yes, what conditions?

10. Are you now taking medication for any physical or psychological conditions? Yes / No. If yes, what medications you taken for which conditions and with what frequency? (If you have asthma medications and/or nitroglycerine, please keep them with you at all times.)

11. If you have any learning disabilities, or other special physical or psychological circumstances, please explain below so we can better serve you during this program.

I hereby certify that the above information is correct to the best of my knowledge.

PARTICIPANT’S NAME:

PARTICIPANT’S SIGNATURE:

DATE:

Financial terms & Conditions

To Serve as Many Needs As Possible, we have provided the following payment options

Cost—The cost of this course is $3600. Class size is limited to 25 students. This price includes all materials and class time for certification including the final week (room, board, instruction) at the Expanding Light Retreat at Ananda Village in California. The price is based on the cost of the final week at the Expanding Light with a standard shared room as accommodations. Transportation to the Expanding Light is not included in the course cost. The student is responsible for making their own transportation arrangements to the Expanding Light and assumes all costs and liabilities.

Deposit—A financial deposit of $400 is required to apply for this course. This deposit is handled in the following way:

• The $400 is comprised of a $100 application fee (payable to Ananda Portland), a $100 reservation fee (payable to The Expanding Light) and a $200 down-payment (payable to Ananda Portland).

• The deposit will not be processed until your application to attend the course is approved. Upon approval of your application into the course your deposit will be immediately processed.

• Once your deposit is processed, the terms outlined in sections Paying the Balance of the Course and Withdrawals &

Refunds apply.

Paying the Balance of the Course—Once your application has been approved there are two distinct ways of paying for the balance of the course. Each choice has separate deadlines and withdrawal terms.

1. Payment Plan—With the Payment Plan you will pay for the course over a period of several months. The payment schedule

is as follows:

• A payment of $800 (payable to Ananda Portland) is due by 8/1/10.

• Five addition monthly payments of $290 (payable to Ananda Portland) are due on 9/1/10, 10/1/10, 11/1/10, 12/1/10,

and 1/1/11, respectively.

• The last payment of $850 (payable to The Expanding Light) is due on 2/28/11.

• For applicants applying after 8/01/10, all payments whose due dates have passed will be immediately due on approval of the application.

• Once the Payment Plan has begun, payment of additional monies (accelerating the payment schedule) does not result in a discount.

• Once you begin the Payment Plan the terms outlined under Withdrawals & Refunds for the Payment Plan apply.

2. Early Payment Option—With the Early Payment Option the entire balance of the course fee is paid at once by 8/1/10. By choosing this option you will receive a $300 discount.

• The entire balance (minus $300 discount and $400 deposit) is $2900 ($2050 payable to Ananda Portland and $850 payable to The Expanding Light), due on 8/1/10.

• The Early Payment Option is not available for students applying after 8/1/10.

• If you elect the Early Payment Option the Withdrawals & Refunds for the Early Payment Option are applicable.

Withdrawals & Refunds—Withdrawals from the course are handled in two distinct ways:

1. Payment Plan

• If your application is not approved by us, your entire $400 deposit is refundable.

• If you withdraw your application prior to 7/15/10 the $400 deposit will be handled as follows: The $100 application fee to Ananda Portland and the $100 reservation fee to the Expanding Light (for a total of $200) are non-refundable. The remaining $200 down-payment is refundable.

• Withdrawal of your application after 7/15/10 causes forfeiture of the entire $400 deposit and all monies paid to date. • Withdrawal from the course anytime after the course has begun causes forfeiture of all monies paid to date.

2. Early Payment Option

• If your application is not approved by us, your entire $400 deposit is refundable.

• If you withdraw your application prior to 7/15/10 and before you have paid the Early Payment Option that is due by

8/1/10, the $400 deposit will be handled as follows: the $100 application fee to Ananda and the $100 reservation fee to the Expanding Light (for a total of $200) is non-refundable. The remaining $200 down-payment is refundable.

• If you withdraw your application after 7/15/10 and before you have the paid the Early Payment Option that is due by

8/1/10, the entire $400 deposit is forfeit.

• Once the Early Payment Option has been paid, withdrawal from the course anytime (before or after the course has begun) causes forfeiture of all monies paid to date. Students are entitled to re-take this program in the future from where they left off. Particulars of a re-take are dependent upon the details/timing of future course offerings.

Class Absences—Due to timing considerations and the requirements of the Yoga Alliance certification program you must attend all of the classes. As a result, you are allowed to miss one class. If you miss more than one class, classes must be made-up in person at a time set by the instructor (before the last week of the course at the Expanding Light Retreat) at a cost of $50 per class/hour.