Course Registration Form

2MPower Teacher Certification Program Registration Form

Fill out the form carefully for registration
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student E-mail
Mobile Number

Area Code Phone Number
Phone Number

Area Code Phone Number
Work Number

Area Code Phone Number
Additional Comments

What is your intention for attending this training? What is your biggest obstacle in participating? *
Where do you feeling strong in your practice? Where do you feeling challenged? *
What else would you like to share with us? *
This training requires you to commit yourself 100%. This includes: being on time to all sessions, being coachable in the moment and being open. . Share with us what this looks like for you. *
How would you evaluate your current health? Excellent Good Fair *
Do you smoke? Do you drink alcohol? Do you use drugs? *
Do you have epilepsy? Do you have diabetes? Are you currently pregnant? *
Have you been hospitalized for a significant injury, condition or illness in the past year? *
Are you currently, or during the last year, have you been under the care of a physician or other health care professional for any significant health concerns? *
Are you currently taking or have taken in the last year any prescribed medications? *
Do you have a mental/emotional disorder? (Including: depression, anxiety, bi-polar, etc.) *
Are you currently, or during the last two years have you been, under the care or supervision of a mental health professional(psychiatrist, therapist, etc.)? *
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2MPower Teacher Certification Program Registration Form