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President's Day, Feb. 18, 2019, Mindfulness for Educators Registration Form
http://www.nancysiegelconsulting.com/      ~    201-390-2809
Your name: First, Last *
Your cell number *
Email address *
Your birthdate: Month, Day, Year *
Your home number *
Address: street, city, state, zip code *
Email address (This is how you will be notified when your registration is confirmed. If you do not receive a confirmation email, your registration did not go through.) *
How did you hear about this training? *
Required
If you answered Friend or colleague: write friend's name
Did you attend NKYTT? *
If yes, which training?
Do you have a mindfulness practice? (Not a prerequisite for this training.) *
Do you practice yoga? (Not a prerequisite for this training.) *
Are you a classroom teacher? Director? Administrator? If yes, what is your position/title/school? What ages do you teach? How long have you been teaching? *
Do you teach yoga? Adults? Children? What ages/grade? Where? How long have you taught?
Do you have a yoga practice? A mindfulness practice? If yes, where, how often, etc. *
If yes, where/when?
Do you hold any Yoga Alliance certifications? RCYT, RYT-200, 300, 500 E-RYT. Please list. *
Why are you registering for this training? Please share what you are looking to learn/take away. *
Emergency Contacts: Please list 2 with name, relationship and phone number. *
REMEMBER TO CLICK SUBMIT AS WELL AS MAKING YOUR PAYMENT: Acceptance and Payment: (PLEASE TYPE YOUR NAME BY WAY OF ACCEPTANCE.) Nancy Siegel Consulting (NSC) reserves the right to accept or reject any applicant. The cost of this training is $125 and I understand it is non-refundable. The information I have provided in this application is true to the best of my knowledge. Nancy Siegel Consulting, LLC does not discriminate on the basis of race, color, religion, national origin, gender, age, marital status, sexual preference, or disability. The information in this application will be treated as confidential. PHOTOGRAPHIC RELEASE: I grant NSC and associates permission to photograph and video me and I agree that they may use such photographs of me, with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. PLEASE TYPE YOUR NAME BY WAY OF ACCEPTANCE. *
PAY HERE 👉 Click on this link to pay tuition: $125 per person, https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=9D4QTTG5BM35S *
Ask about group school discount. *
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