Meditation Instructor Training Application Form
Dear Applicant: Thank you so much for your interest in the Meditation Instructor Training Program for non-diet clinicians. We will give your application every consideration. Please take some time to give thorough answers to the questions below. This program is not for everyone and we want to make sure it matches up with your intentions and background. With appreciation, Jenna
Email *
Your answer
First Name *
Your answer
Last Name *
Your answer
City *
Your answer
State/Province *
Your answer
Country *
Your answer
Submission Date *
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Currently, what is your understanding/practice of the non-diet or weight-inclusive approach? *
Your answer
Have you taken any related trainings such as Intuitive Eating certification with Evelyn Tribole, Body Trust provider training with Be Nourished, Body Image Workshop training with Fiona Sutherland and Marci Evans? *
Your answer
What is your meditation practice currently? Please give us some detail. For example, how often do you practice, for how long and what type of meditation do you practice? *
Your answer
Have you taken any other courses in meditation or mindfulness? If so, please list the names and dates here. *
Your answer
The technique we will instruct you in is called Shamatha-Vipashyana. It is a practice done with eyes opened (rather than closed). Does this raise any questions for you? *
What is your current job or area of expertise? Please tell us a bit about your work, vocation, and professional or creative interests. *
Your answer
Please let us know in approximately 50-100 words (or more, if you like) what you hope to gain from this experience. It could be anything from “I simply want to deepen my own practice” to “I want to teach meditation as part of my professional work.” *
Your answer
How do you anticipate applying what you will learn in this program, as far as you know now? Please let us know in 50-100 words or more, if you like. *
Your answer
Note: Meditation is not for everyone. For example, people with PTSD or a history of trauma may actually intensify their suffering rather than relieve it. Please let us know if any of these apply to you. These are definitely not reasons to reject your application but will help us to get to know you better to ascertain if this program will serve you. Please check any or all that apply. *
Required
There is a mental or physical health condition not on this list that I would like to make you aware of: *
Your answer
If you are in recovery, for how long?: *
Your answer
Please list any current or relevant mental health diagnoses. *
Your answer
Please add anything else you would like us to know about you. *
Your answer
Will you be using this course to obtain CEU’s for the Commission on Dietetic Registration? *
Will you be using this course for credit in any other association? If so, please let us know which: *
Your answer
How did you hear about this course? *
Required
Note: Attendance at all classes and check-ins is mandatory. If necessary, one class or check-in may be missed, but it may not be the opening session, class one or class nine. Please check the following. If I’m accepted, I certify that I can attend all of the classes and check-ins below (one class or check-in can be missed, although not the Opening Session, Class one or Class nine). *
Required
Note: Your full attention and participation is required at each class and check-in. If accepted, I will be able to give my full attention to the classes and check-ins (I will not be driving, walking, or otherwise engaged in a separate activity). *
Note: It is the student's responsibility to ensure adequate technology and bandwidth to attend all classes and check-ins, even if traveling. I possess the technology and bandwidth to attend video teleclasses and agree to show up via webcam for each session. *
I agree not to teach others what I am learning in this program until it is completed, my own practice is stable, and I have successfully fulfilled all the requirements. *
I understand that successful completion of this program is based on various factors including, but not limited to, mandatory attendance, class participation, written homework, and demonstrating personal understanding of the material. If I fail to meet these requirements, I acknowledge that I am not guaranteed a certificate. *
Questions?
Once accepted, applicants must pay within 5 days to secure their spot in the program. If you have any questions about this application or need clarification about the course, we are here to help! Please contact us at jenna@jennahollenstein.com.
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