STUDENT QUESTIONNAIRE + WAIVER

Welcome to your Shivakali Yoga Teacher Training!  To help us serve you better and to prepare for the training, please fill out the below questionnaire and waiver forms (these forms are separate, please make sure to complete both).  If there is any additional information you think we may want to know, feel free to add below or send us an email with additional information!

STUDENT QUESTIONNAIRE

ALL INFORMATION YOU PROVIDE IS CONFIDENTIAL, YOUR ANSWERS WILL ONLY BE SHARED WITH THE FACILITATORS OF YOUR SPECIFIC PROGRAM.

Phone # (include country code):
Emergency Contact:
Relationship:
Emergency Contact Phone #:
What is your age and occupation?
Any injuries or illnesses we should be aware of?
Please list any dietary restrictions or food allergies:
As immersion programs can be intensive both physically & emotionally, is there any other personal information we may want to be aware of?
How long have you practiced yoga?
What is your yoga history, experience, styles practiced & previous training?
Any other areas of yoga or spirituality of special interest to you?
What are your goals in participating in this program? Why did you choose to take this teacher training?
What are some of your skills, hobbies, athletics, etc.?
Is your birthday during the program? If so, what is the date?
How did you hear about us?

 

 

WAIVER + STUDENT AGREEMENT

PLEASE READ EACH STATEMENT BELOW IN ITS ENTIRETY, AND CHECK EACH BOX TO INDICATE YOU ACKNOWLEDGE AND AGREE. 

IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO CONTACT US AT: INFO@SHIVAKALIYOGA.COM

I understand that yoga includes physical movements, as well as an opportunity for relaxation, stress reduction, and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that Vinyasa Yoga is a physically challenging practice, and if I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from an instructor. I also understand that the practice of yoga is much deeper than the physical body, and that the most important part of the practice is my ability to breathe comfortably. I recognize that there is no competition encouraged in this training, including competition with my own ideas of what I think I should be able to accomplish! I will listen to my own body and take rest or modify postures with confidence any time I feel the need. I assume full responsibility for any and all physical damages that I may incur through participation in these activities.
I recognize that through the course of this program, in the studies of yoga philosophy, meditation, chanting, bodywork, sharing circles, in the physical practice of yoga, in conversations/relationships with my fellow students and teachers, and simply throughout daily life, that personal challenges may also arise. I take responsibility for participating in a course of this nature, and I will honor what arises as opportunities for growth. I will make my own decisions about how to proceed in light of any personal challenges, and will most importantly always remain compassionate and loving towards myself.
I waive my right to any reimbursement or refund from this course for any reason. I recognize that I have the right to leave the course at any time, and that my decision will be fully supported should I decide to leave the program. I also recognize that this program is non-refundable, thus I will forfeit both my certification and my financial investment in the program should I leave the course for any reason whatsoever. I also accept the terms that, if I am to leave the course and miss classes for any length of time outside allotted free times (barring health emergencies and pre-approved absence by the instructors), I will not be accepted back into the program to preserve the solidarity of the program/group. I understand that the retreat center is a private location and outside guests are not allowed onto the retreat center property, unless prior approval is obtained from the instructors. This approval is rarely granted and will be at the sole discretion of the course leaders. I recognize that due to Yoga Alliance guidelines, I must attend all classes on time to receive my certification from Shivakali Yoga, and there are no makeups offered except occasionally in the case of severe health emergencies. I understand that attendance will be taken for classes, and I am expected to arrive on time. I acknowledge that if I am 15 minutes late to class three or more times, I may be asked to leave the retreat to preserve the integrity of the program/group. Lastly, I am informed that the leaders of the course have the right to remove any participant from the program and retreat center at any time, and this decision is at their sole discretion, should they feel it necessary to ensure the safety and security of the other participants and/or of the training in general. As with any other case of an individual exiting the program, in this case no reimbursement nor refund will be granted.
I acknowledge that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I further acknowledge that Yoga, Meditation, Yogic Philosophy and Spirituality are not substitutes for therapy, counseling, or psychiatric diagnosis, care or treatment. Yoga is not recommended and is not safe under certain medical conditions. Some poses are not healthy for some body types simply by virtue of bone structure, due to previous injuries, or many other contributing factors. By signing, I affirm that I am in good physical health and good mental health to participate in such a fitness and spiritual program. In addition, I will make the instructors aware of any medical or psychological conditions or physical limitations that may affect my participation or the rest of the group before beginning this course. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga & engage in a program of this nature, and participation is at my own risk.
Shivakali Yoga is committed to maintaining a program environment free of discrimination and harassment. Discrimination and harassment based on race, religion, sexual orientation, gender/gender identity, national origin, disability, age, and sexual harassment will not be tolerated during the program or on the grounds of the retreat center. Such conduct is subject to discipline, up to and including removal from the program. Sexual harassment is unwelcome conduct of a sexual nature which makes a person feel uncomfortable, offended, and/or intimidated. Examples of behavior which may constitute sexual harassment include but are not limited to: Unwelcome physical contact such as pinching, stroking, kissing, or inappropriate touching, unwelcome comments of a sexual nature on another’s appearance, and repeated unwanted requests for private social time and/or physical intimacy. In case of any physically intimate relationship that may develop during a program, clear verbal consent is an absolutely necessity for engagement. I also understand that Shivakali Yoga teacher trainers choose not to enter into sexual or romantic relationships with students during the course. I will support my teachers’ commitment by not soliciting them or making suggestive comments towards them of a sexual or romantic nature.
By registering for this event, I give my consent to have my picture taken in film & video recording, and for these images to be used in Shivakali Yoga’s promotional activities. I further agree, that if I engage in any physical exercise or activity with, receive any kind of bodywork or treatment from, use any equipment owned by, or heed any advice offered by Shivakali Yoga, Serge Berliawsky, Gloria Baraquio, Amber Lee, or any other Shivakali Yoga staff member, I do so at my own risk. I will practice good judgment and assume responsibility for my decisions. This includes, without limitation, my use of any and all facilities at the Retreat Center this event is being held at. I also hereby assume all risk of injury or illness that may result from being in this local environment, and take responsibility for researching best practices with regards to health, diseases and vaccinations, local animals & insects, swimming or surfing, hiking, eating foods & drinking local water/beverages, walking on unstable pathways, earthquakes, natural disasters, and anything else that could affect my health and well-being. I agree to assume all risk of injury, illness, damage and/or loss to myself or my property that might result from my participation in this event, including any loss or theft of any personal property. I understand that the retreat center is a committed to preserving the local environment by existing in harmony with the ecosystem around it. It is rustic yet clean, vibrant and charming. I take responsibility for joining a course at a retreat center that values the local ecology and conserves resources to maintain a harmonious balance with the land it is built upon.
I hereby agree to irrevocably release and waive my right to bring any legal action or assert any claims against Shivakali Yoga, Serge Berliawsky, Gloria Baraquio, Amber Lee, and all other staff members of the Shivakali Yoga organization. I HAVE READ THE ABOVE DOCUMENT IN ENTIRETY, AND FULLY UNDERSTAND AND AGREE TO ALL TERMS OF THIS AGREEMENT.
I am signing this agreement voluntarily and recognize that my typed signature & submission of this form serves as a complete and unconditional release of all liability, to the greatest extent allowed by law in the United States of America. TYPE SIGNATURE + DATE:
MAY THESE AGREEMENTS HELP TO CREATE POSITIVE, HARMONIOUS, CONSCIOUS AND UPLIFTING RELATIONS BETWEEN ALL PARTICIPANTS OF THIS COURSE ~ OM SHANTI!
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SHIVAKALI YOGA    I    951 MICHELTORENA ST.  LOS ANGELES, CA 90026    I    T:310.341.0004

COPYRIGHT © 2016 SHIVAKALI YOGA, ALL RIGHTS RESERVED.

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