100 Hr Trauma Informed Yoga Teacher Training Registration Form
Dates: 1 - 15th December 2019
Venue: The Vajra Hotel, Kathmandu, Nepal
Contact us at atira@atiratan.com. www.atiratan.com

All answers are strictly confidential and will not be shared with anyone else.
Thank you for sharing and taking the time to let us know a bit more about you.
Email address *
First/ Last Name *
Phone Number *
Address
Date of Birth *
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Emergency Contact Name & Phone.
Skype Username
Facebook Profile
This is optional but a good way for us to share group information so highly recommended
What style(s) of Yoga do you practice regularly?
Are you a yoga teacher?
Clear selection
If you're an active yoga teacher, what classes do you teach and what kind of community do you serve?
Clear selection
How long is your daily practice (in hours)?
If you meditate, how long have you been meditating, and how often do you meditate?
Approximately what year did you start to practice and/or teach Yoga?
Please provide the names of your principal teachers or schools.
Do you suffer from any medical condition? Are you taking any medications?
If you are under medical treatment or supervision, please tell us about it as thoroughly as you can.
Do you have any personal trauma history? If so, please provide details, as well as the healing work that you've done in recovery from your personal trauma.
If you are currently receiving psychotherapy, psychiatric treatment, and/or counselling, please tell us about the history and processes you are using currently.
If you are using any prescription medication, please indicate type, dosage, and frequency of intake.
Are you currently experiencing any injuries?
List all that you think are relevant including chronic and acute.
Is this your first time to Nepal?
Clear selection
How did you hear about this Yoga Teacher Training?
Clear selection
What is your main interest in taking a trauma informed training - personal trauma healing?
Clear selection
Dietary restrictions *
I have read and understood our Yoga Teacher Training terms and conditions, and will be fully responsible for you are responsible for your own health and wellbeing during the retreat. Atira Tan & Gemini Adams will not be held liable for any injuries or other medical or mental health problems that may occur, are sustained or aggravated during or after your time on this training. *
Required
Thank you so much for filling out this registration form! We look forward to journeying with you.
With Love, Atira & Gemini
A copy of your responses will be emailed to the address you provided.
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