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Summer 2019, Mindfulness for Educators Registration Form      ~    201-390-2809
Your name: First, Last *
Your cell number *
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.) *
Day/s will you be attending *
How did you hear about this training? *
If you answered Friend or colleague: who is your friend
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.(Not a prerequisite for this training.) *
Why are you registering for this training? In a few sentences, please share what you are looking to learn/take away. The more you offer, the more I can try to meet your needs. *
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 fee 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, 2 days $285 per person, 👉 Click on this link to pay:
PAY HERE, 1 day $150 per person, 👉 Click on this link to pay:
GROUP SCHOOL DISCOUNT. To discuss: 201-390-2809, or
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