Please answer the following questions.

Date of Application:
Name:
Address:
Business Phone:
Home Phone:
Mobile Phone:
Email:
Skype:
Current Occupation:
Date of Birth:
Male/Female:

List all your workshops and class experience in the 5Rhythms including the dates (month and year)
name of the teacher and subject (e.g. Mirrors, Heartbeat, Waves....).
If you are a 5Rhythms teacher, you need only put that in here.

Describe briefly any psychological work you have done, i.e. psychotherapy, counselling, group process:

Do you have any history of psychiatric treatment, including medication or hospitalizations? Are you currently on any medications?

Do you have any heath conditions we should know about?

What regular physical practices do you have, e.g. yoga, sports, etc.?

Describe a specific goal or intention you have in participating in this group?

Emergency Contact Information.

Please provide contact information for someone we can call for you in case of any emergency.
Providing the name of an emergency contact is a requirement for attending this workshop and
you are agreeing to allow us to contact this person if necessary at any time during the workshop,

In case of emergency please contact:

Name:
Their relationship to you:
Business Phone:
Home Phone:
Mobile Phone:
Email: