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FULL NAME

Sex

Birthday
Occupation

Address
Contact
Number(s)
Email Address

In Case Of
Emergency
Name:
Relationship:

Contact Details

Do you have any medical conditions we should be aware of?

Are you currently on any medication / therapy?

In this Teacher Training Program

What do you expect of the program?
What do you expect of yourself?
What other types of Teacher Training / Workshops would you like to attend?

Who referred you? How did you know about us?

Payment Method
Early Bird
Regular Rate

P60,000 on or before September 1, 2015

P65,000 payments made after September 1, 2015

All payments for this Teacher Training are to be paid in FULL upon submission of this application form.
Failure to give payment with this form deems the slot unreserved.
NO REFUNDS after August 15, 2015.
CASH

Please visit Beyond Rockwell to settle Teacher Training Fee

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CREDIT CARD
CHEQUE
BANK DEPOSIT

Please visit Beyond Rockwell to settle via Credit Card.

Extra % will be charged to process credit card payments.
Please write all cheques to: BEYOND ROCKWELL GLOBAL,
INC.
BDO
Beyond Rockwell Global Inc
0049 0009 2986

I have truthfully filled out all necessary information in this application form.
I am aware that MINDFUL BIRTH: Pregnancy, Birth and Baby, is here to serve me by sharing knowledge of Yoga and health.
I understand that the practice of Yoga and exercise involves physical movement, which may from time to time be strenuous,
and that such practice carries some risk of injury. I also understand that I must judge my own capacities with respect to
practicing yoga and exercise during any classes offered through the Mindful Birth Teacher Training Program.
I acknowledge that it is my responsibility to inform the instructor, when I begin a class, of any injury or other condition that
might affect my ability to participate, and to inform the instructor immediately if any injury occurs during class. I understand that
from time to time during classes offered through MINDFUL BIRTH, the instructor may give hands-on assistance to facilitate the
understanding of postural alignment. If I do not want such assistance, I will inform the instructor at each class I attend.
I hereby agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a
result of participating in the classes of yoga, exercise, and/or meditation offered through MINDFUL BIRTH. I voluntarily waive
any claim I may have against any person or entity in any way involved therewith, including without limitations, its principal,
instructors, independent contractors, employees, agents and representatives and their successors and assigns.
I have carefully read the release, fully understand and agree to the above.

__________________________________
Printed Name and Signature

______________________
Date Signed