Urban Zen Integrative Therapy Training Application

To apply please fill out the following application form or download it and complete the application.

Include a headshot with your submission.

Email, mail to Life Energy Institute/ UZIT Program, 19600 Cave Way, Topanga, CA 90290, fax (310) 455-9832.

Urban Zen Registration

2020 UZIT APPLICATION

Please write n/a on the application if not applicable to you
Date*
MM slash DD slash YYYY
PERSONAL/CONTACT INFORMATION:
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone*
Evening Phone
Fax
Email*
Best time and way to reach you?*
Gender*
Age*
Single/Married/Children?*
EMERGENCY CONTACT INFORMATION:
Name*
Relationship*
Phone*
Alt. Phone
DEADLINE FOR APPLICATION SUBMISSION: Oct 1st, 2020
INTEREST IN & GOALS FOR THIS PROGRAM:
1. How did you hear about the Urban Zen Integrative Therapy training program? What attracted you to this particular program?*
2. Please describe your interest in becoming an Urban Zen Integrative Therapist.*
3. What is your level of commitment to the mission of the Urban Zen Foundation in the area of wellness?*
YOGA EXPERIENCE:
4. Please provide a general overview of your yoga experience, if any. How long have you been practicing yoga? What styles have you practiced and what style do you currently study?*
5. Have you completed a teacher training program? Are you a “Registered Yoga Teacher” with Yoga Alliance?*
6. Do you have a daily asana, pranayama, meditation practice? Please provide details.*
7. How is your yoga practice enabling you to serve?*
8. Do you currently teach yoga? If so, for how long have you been teaching and where? Do you have liability insurance? If you do not currently teach yoga, do you plan to teach yoga in the future?*
OTHER (NON-YOGA) EXPERIENCE:
9. Please describe your educational background (degrees, institutions, locations, and dates), from high school to college and beyond.*
10. Do you have any credentials in the allied health field (e.g., LMT, PT, RN, MSW, etc.)? Please provide details on licensure and liability insurance.*
11. Do you have First Aid/CPR certification?*
12. What other related disciplines do you study/practice? Do you have experience with any of the other “integrative therapies,” i.e., massage/healing touch, aromatherapy, or nutrition?*
13. Do you have any volunteer or community service experience that is relevant? Please describe.*
EXPERIENCE WORKING WITH PATIENTS AND ILLNESS:
14. Do you have experience working in the hospital setting or allied health care settings? Please provide specific details.*
15. Do you have experience working with specific conditions, illnesses, or injuries? Please describe.*
16. Have you had the experience of being a care provider for a family member or a friend? Please describe.*
17. Have you had personal experience with an illness or an injury? Please describe.*
18. Do you have any experience with death and dying? Grief, loss, and bereavement?*
19. Tell us how you feel about working with, for example, medical and surgical oncology patients. Are you comfortable working with patients who might be physically disfigured or are assisted by breathing tubes and drains?*
20. What are your goals/expectations for working with patients in the hospital setting?*
GENERAL QUESTIONS:
21. Describe any limitations or challenges that you face, physical or otherwise.*
22. Please provide any additional information that you would like to share.*

Urban Zen Integrative Therapy Training Application

Urban Zen Registration

2020 UZIT APPLICATION

PERSONAL/CONTACT INFORMATION:

EMERGENCY CONTACT INFORMATION:

INTEREST IN & GOALS FOR THIS PROGRAM:

YOGA EXPERIENCE:

OTHER (NON-YOGA) EXPERIENCE:

EXPERIENCE WORKING WITH PATIENTS AND ILLNESS:

GENERAL QUESTIONS: