​Information for a teacher/facilitator

 

Please write clearly

 

 

NAME_______________________________________________________________________________

 

ADDRESS____________________________________________________________________________

 

 

 

E-MAIL ADDRESS

 

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TELEPHONE _____________AGE_____MALE/FEMALE_______OCCUPATION_________________

 

MAIN LANGUAGE SPOKEN_________________IS ENGLISH CLEARLY UNDERSTOOD_________

 

WHO TO CONTACT IN CASE OF EMERGENCY (name, address, phone number)

 

HOW DID YOU FIND OUT ABOUT THIS COURSE_______________________________________

 

PLEASE INDICATE YOUR EXPERIENCE/INTEREST IN THIS AREA

 

THE FOLLOWING CONFIDENTIAL INFORMATION EYES ONLY OF TEACHER/FACILITATOR

 

THIS INFORMATION ENABLES TEACHERS TO DIRECT YOUR DAILY PRACTICE IN

APPROPRIATE WAYS.

 

DO YOU HAVE ANY PHYSICAL HEALTH PROBLEMS SUCH AS ASTHMA, DIABETES,

EPILEPSY, HEPATITIS, OR HIGH BLOOD PRESSURE? NO_________YES___________

If yes, please give details, such as symptoms, duration, and recurrences:

 

 

DO YOU PRESENTLY, OR HAVE YOU IN THE PAST, EXPERIENCED SUFFERING FROM

ANY EMOTIONAL OR PSYCHOLOGICAL CONDITIONS SUCH AS DEPRESSION, SLEEP

DISORDERS, EATING DISORDERS, ABUSE, ETC.?  (Please give information on any previous

treatment, medications and occurrences:

 

ARE YOU CURRENTLY USING ANY MEDICINES FOR ANY PHYSICAL OR PSYCHOLOGICAL

CONDITION? PLEASE INDICATE DRUG NAMES AND CONDITION TREATED:

 

 

I AGREE TO TAKE FULL RESPONSIBILITY FOR MYSELF DURING THIS COURSE.

 

I AGREE TO OBSERVE THE GUIDELINES AND INSTRUCTIONS THROUGHOUT THE DURATION OF THE RETREAT.

 

Please write you signature below.

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Thank you.