Farm Wellness Retreats Training Application Process
We are happy you are considering training with us, and the application process is to support everyone is setting ourselves up for ease, enjoyment and success. We kindly ask that you complete the following:
1) Review program requirements, costs, locations at www.farmwellnessretreats.org
2) Complete the following application form and include a copy of your yoga teacher training certificate, (and current CRP, first aid and Liability Insurance coverage if you have it, as these are eventually required to run Farm Wellness Retreats).
3) Include a non-refundable $25 processing fee by check to Farm Wellness Retreats.
4) We will send you an email confirmation of our admission decision. We reserve the right to request an additional phone interview if this is necessary to arrive at an admissions decision. After acceptance, you will contact the host facility for our training to book available housing options and make final payment in full.
NOTE: Sept 2010 on-site housing is limited so early registration and payment is strongly encouraged, and off-site arrangements will be solely the participant’s responsibility.
General Training Admission Requirements:
1. AGE: You must be at least 18 years of age.
2. LANGUAGE: At this time, you must demonstrate English Language competency as our trainings are in English. (Note: we are eager to have this program offered in many languages and countries as soon as certified trainers complete all the requirements).
3. PROFESSIONAL STANDING: We are currently focused on training 200-hour certified yoga instructors as this creates a base competency in leading mindfulness based wellness and movement experiences. If you do not meet this requirement, you can train with and teach with someone who does fulfill this program requirement.
4. PHYSICAL, MENTAL and EMOTIONAL PREPAREDNESS
Given that trainees will be offering an emotional, physical and mental container for others, you must demonstrate medical and mental-health readiness to fully participate in the demands of the training and role. Additional documentation and/or clinical evaluation to evaluate medical and mental/health preparedness may be required.
Application Check List
ð Completed and signed 3 page application
ð $25 non-refundable application fee
ð Copy of 200 hour Yoga Alliance Certification (optional: CPR, first aid and liability).
ð When your application is in the mail, please email
APPLICATION Page 1
Please print in BLOCK letters to ensure legibility
Date of Application Date received (office use only)______
First name ______Last Name ______
Name you prefer to be called ______
Date of birth ____/_____/_____ Age ______Gender ______
Address ______
Phone Day ______Evening ______
Email ______
(optional) cultural background/ethnicity ______
Emergency Contact
First and last name______
Relationship to you ______
State or country/time zone ______
Day Phone ______Evening Phone______
Email ______
How did you find out about our training program?
______
Education
List relevant schools attended and degrees/certifications obtained
______
Work Current Occupation(s) ______#yrs ______
Past Relevant Occupation(s) ______
______
Are you fluent in English? Yes ð No ð If no, please describe your level of proficiency
Do you have current CPR and First Aid certification? Yes ð No ð
Do you have current professional liability insurance? Yes ð No ð
For how many people and how much coverage?______
Company ______website or contact info ______
Date of Expiration ______
YOGA CERTIFICATION AND TEACHING EXPERINCE
Are you a 200hr certified yoga teacher from a Yoga Alliance school? Yes ð No ð
Date of certification ______
Style of yoga ______
How many years have you been teaching yoga ______
What is the duration and frequency at your most and least involved phases (times per week/ average number in class/class content or styles)
Dates # classes # in a class Class content
Most
Least______
Criminal Background
Have you ever been charged or convicted of a felony or a lesser crime? Yes ð No ð
Have you ever been incarcerated? Yes ð No ð
If yes, please explain ______
HEALTH INFORMATION
Check any of the following you currently have or have had in your lifetime
ð Respiratory Conditions ð High Blood Pressure
ð Heart Conditions ð Osteoporosis osteopenia
ð Diagnosed mental health conditions ð Chemical sensitivities
ð Environmental or food allergies ð Allergies to stings
ð Seizures or strokes ð Diabetes
Are you under medical treatment for any physical or psychological condition?Yes ð Noð
Are you currently pregnant or potentially pregnant during the training? Yes ð No ð
Have you ever been hospitalized for a psychiatric condition? Yes ð No ð
Do you have chronic pain, physical limitations, or disabilities Yes ð No ð
Have you had a serious illness or major surgery within the last 5 years? Yes ð No ð
Are you in recovery from an addiction? Yes ð No ð
Have you ever been in a treatment program for alcohol or substance abuse? Yes ð No ð
Do you have a communicable disease? Yes ð No ð
If you answered yes to any of the above questions, please describe fully.
______
List any prescription medications you are currently taking, indicating dosage and frequency of intake, and what symptoms/conditions require the medication. We do not need to know about birth control or cosmetic prescriptions.
______
______
Briefly share (point form is fine) about:
other movement practices that you draw on in your current life and teaching
experience teaching movement to people with health conditions/special needs
experience leading workshops
other teaching experience
community organizing experience
gardening, farming experience
Short answer
What about this training most motivates you? ______
Why are you interested in being a part of these programs at this time in your life?______
Do you have a particular area of interest?______
What strengths do you bring?______
After reviewing the training process online, what potential challenges do you foresee for yourself given the diverse skills, physical demands and intensive nature of being trained?
If you successfully complete all of the training requirements, please describe any plans or visions you may already have for implementing this model back home.
Do you foresee running retreats at one or multiple sites in your local area Yes ð No ð
One retreat a year or more ( guess at #)___
Leading with other local professionals Yes ð No ð Type: ______
I understand that Stephen Buhner’s beautiful and life changing chapters about the heart in the book The Secret Teachings of Plants,pgs 1- 158 is very strongly recommended reading to be completed prior to the training.
I understand that Farm Wellness Retreats assess enrollment three weeks prior to the training, and reserves the right to cancel programs if necessary, so any transportation arrangements are the participants sole responsibility.
I understand that although many components of this training are offered freely to enrich any teaching endeavor, that the Farm Wellness Retreats is a distinct model, with specific copyrighted curriculum, methodology, language, schedule, and marketing materials. I agree that if I complete certification and teach this model, that I will acknowledge and conform to these standards and Farm Wellness copyrights in order to be able to have a continued affiliation with the Farm Wellness Retreats model, materials and organization.
I acknowledge that all information submitted in this application is true and accurate.
I understand that incomplete or inaccurate information may result in non-acceptance or dismissal from the training process.
Sign Name Date
Thank you
Mail to: Farm Wellness Retreats PO Box 603 Lenox, MA 01240 413-442-5477