Yoga as Resistance Fall 2017 Interest Form
Thank you for your interest in Yoga as Resistance. This program is a 3-week series, taking place Wednesdays from 3:30-5 pm on October 18, November 1, and November 15 (Weeks 3, 5, & 7) in the Cross-Cultural Center Ring Room.

You will receive an email with more information about the program after you complete this interest form. Because space is limited, a submission to this interest form does not guarantee a spot in the program. Spots for the program will be given to those who are first to submit to this form.

Name
Your answer
UCI Email
Your answer
Phone Number
Your answer
UCI Student ID
Your answer
Gender
Your answer
Race/Ethnicity
Your answer
What is your expected graduation year?
Why are you interested in this program?
Your answer
What do you hope to gain from this program?
Your answer
What, if any, is your experience with yoga?
Your answer
Please select your response to the statements below.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I practice self-care on a regular basis.
I have a self-care action plan.
I have a positive, healthy sense of self.
I have a commitment to social justice.
Will you be able to make all three sessions (April 11, 18, and 25) from 5:30-7 pm?
Are you allergic to oils or strong scents?
Do you have any accommodation needs?
Your answer
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