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Yoga as Resistance Spring 2017 Interest Form
Thank you for your interest in Yoga as Resistance. This program is a 3-week series, taking place Tuesdays from 5:30-7 pm on January 31, February 7, and February 14 in the Cross-Cultural Center Ring Room.

You will receive an email with more information about the program after you complete this interest 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 (January 31, February 7, and February 14) 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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