|Day Phone:||Evening Phone:|
|Emergency Contact Phone #:|
|When would you like to begin the Integral Qigong and Tai Chi training program?|
Please list all
post-secondary institutions you have attended including non-degree granting
schools. Attach additional pages if necessary
|Name of Institution, Location||Dates Attended||Degree|
1) Have you completed
any instruction and personal practice in one or more forms of Qigong and/or
Tai Chi? The more varied your practice and experience, the better prepared
you will be to teach effectively.
YES ____ NO ____
If YES, please list the forms and number of years have studied, practiced or taught each form. Attach additional pages if necessary
|Form||Years Study||Years Practice||Years Teaching|
2) Will a family member, friend
or spouse be enrolling with you for this training? YES ____ NO ____
If YES, please list.
3) Do you have a roommate preference?
YES ____ NO ____
If YES, please name.
4) Were you referred by a previous
graduate of the Institute of Integral Qigong and Tai Chi (IIQTC)?
YES ____ NO ____ If YES, please name.
5) Do you have any limiting
physical or emotional conditions, which might affect your full participation
in this program? YES ____ NO ____ If YES, please list physical conditions
or considerations, which may limit your participation. List any prescription
You will need to be comfortable with physical movement for extended periods of time and training. If you currently receiving medical or psychiatric treatment, please discuss your participation with your physician and follow their recommendations.
6) Are you comfortable participating in a group training environment, which requires leading small group practice sessions and giving and receiving feedback? YES ____ NO ____ If NO, please describe or list your concerns.
7) List any other credentials you may have in nursing, health care provider, bodywork, teaching, acupuncture, counseling, occupational therapy, physical therapy, social services or coaching.
8) On a separate sheet of paper, please document your goals or purpose for taking this training in a Letter of Intent. Help us to focus the training for you by sharing your personal vision and interests. Include in this letter, whether you are registering to become a teacher or for a personal Qigong intensive.
9) Circle your Tuition, Lodging,
Meals Fee Plan choice below:
Tuition for Institute of Integral Qigong and Tai Chi Level 2 Integral Tai Chi Facilitator, 7 nights lodging, meals, break refreshments, and on site training materials. Commuter fees include Level 2 tuition, food plan with 21 meals and on site training materials.
Price does not include required texts and videos, round trip airfare and ground transportation to and from Sunrise Ranch.
10 ) What are your dietary preferences? To better serve you, please answer questions A-G.
A. Are you a vegetarian or vegan ? _______________________________
B. Do you eat chicken?
C. Do you eat fish?
D. Do you drink coffee or decaffeinated coffee?
E.Do you eat desserts?
F. Do you have food allergies or sensitivities?
G. Other considerations?
Cancellation and Refund Policy:
The Institute of Integral Qigong and Tai Chi (IIQTC) reserves the right to cancel any program, at any time. A full refund, less a $100 processing fee, will be offered for cancellations made on or before the close of business 5:30 pm PST, Thursday March 15, 2007. No refund will be offered for cancellations after April 1, 2007, if you do not show up, or if you leave the program early. For cancellations between March 15, 2007-April 1, 2007, a full refund less a $300 processing fee, will be offered. For cancellations after April 1, 2007, partial credit of tuition will be offered on a case by case basis ONLY due to extenuating circumstances such as serious illness, accident, death in the family, or family emergency. No refunds will be offered for lodging/meal plans under these circumstances.
I certify that the information presented in this application is true and correct.
To register by mail, fill out completely, and enclose check or money order payable to IIQTC. Mail to:
Institute of Integral Qigong and Tai Chi
243 Pebble Beach Dr.
Goleta CA 93117
If you have any questions call 805-685-4670 or email firstname.lastname@example.org.