Embodied Mind Evolved Heart Registration

Registration Form Embodied Mind Evolved Heart Teacher Training

yoga and mindfulness meditation teacher training for mental health professionals with NeLi Martin

Personal Details

Name*

First Last

Address*

Street Address Address Line 2 City State Postcode Country

Email

Phone Number(s)

Date of Birth

I confirm I identify as a woman

Yes
No

Mental Health or Health Qualifications (please state what type and to what level. If Health Quals, please state your interest in Mental Health)

Occupation and Current Job Role

Yoga Practice

Please describe in detail the kind(s) of yoga and meditation practice you do, for how many years you have practiced and how frequently? (This is NOT a prerequisite, but you do need to maintain a practice throughout the course).

Meditation Practice

Please give details of any yoga / mindfulness / meditation courses or retreats that you have attended. We are looking for the name of the retreat/course, year you attended, the length of the retreat/course, who taught the course, and where it was held. If you do not recall every detail, that is fine. Please just tell us what you can recall. (This is NOT a prerequisite, but you do need to maintain a practice throughout the course)

Your interest, intention and hopes in registering for this course

Dietary requirements

Special dietary restrictions

Special dietary restrictions that are essential for you during residential courses, other than vegetarian

Dairy Free
Gluten Free
Vegan
Other Allergy

Any other special needs?

Accomodation

$135 per person per night covers food and accommodation. Rooms available at Bellbunya are twin share or dormitory (3 share). You may choose other local accommodation at your own discretion and cost.

Will you be sleeping in the centre’s accommodation?

Yes
No

or will you be camping

(slight cost saving; you need to bring your own tent / camping gear)

Yes
No

If intending to sleep in a camper van, please give registration number

If you are travelling by car and can offer a lift, please say from where

and number of people

We will do our best to organise lift shares. We will do this by gathering information from you all and we will put people in contact with one another. We can’t, however take responsibility for getting you to the course.

If you’d like a lift, please say from where

Medical

Do you have any sleep issues that may disturb others?

Yes
No

If yes, please describe

Do you have or have you had any alcohol or drug dependency?

Yes
No

If yes, please describe how this affected your life and state whether past or current

What (if any) psychological and mental health issues have you had in your life?

Please describe how they affected your life and state whether past or current

Please list any medication you are currently taking for these issues

Do you have any medical condition(s)?

Yes
No

If yes, please describe

Contact person in case of emergency

Relationship of contact person (eg, friend, partner, parent)

Phone number(s) of contact person

Acknowledgement of Risks

Acknowledgement of Risks During the process of learning to teach yoga and meditation, people can experience intense and unusual psychological, spiritual and/or physical states. While yoga can be safely practiced by anyone, you need a certain level of physical and psychological robustness to undertake training to become a teacher. It may not be suitable for all people. At this particular centre in Queensland there are also risks from walking over hilly terrain and the nearby creeks, risks in swimming in the creek, or from walking in the bush (uneven paths, flora, fauna, e.g. snakes, spiders, ticks etc.). In voluntarily participating on this course I am aware that I may be exposed to risks that may lead to psychological issues, injury or death. I have considered the risks before choosing to acknowledge this form. I still wish to participate in the course. I accept that in ticking the box below, I will take full responsibility and liability for my own property, health and safety.

*

By ticking this box, I acknowledge these risks

*

I confirm that all the information above is correct to the best of my knowledge.

Note: all information here is kept confidential and will be seen only by the managers and teachers.

Payment Process

To secure your place, please complete and submit this form and make payment to
Commonwealth Bank Australia
(Janelle Louise) NELI MARTIN
BSB 06 4003
Acc 00607279
Please use your initial and surname and “EMEH” in the reference

If you wish to use a payment plan, please speak with neli about this before making the deposit.

e neli@nelimartin.com
m 0420221461

Details of your investment https://nelimartin.com/embodied-mind-evolved-heart/

Phone

This field is for validation purposes and should be left unchanged.