Meditation Instructor Training Application Form

Email*

Name*

First Last

City*

This helps us establish time zones

State/Province*

This helps us establish time zones

Country*

Submission Date*

What is your meditation practice currently? Please give us some detail. For example, how often do you practice, for how long and what type of meditation do you practice?*

Have you taken any other courses in meditation or mindfulness? If so, please list the names and dates here.*

The technique we will instruct you in is called Shamatha-Vipashyana. It is a practice done with eyes opened (rather than closed). Does this raise any questions for you?*

Yes
No

What is your current job or area of expertise? Please tell us a bit about your work, vocation, and professional or creative interests.*

Please let us know in approximately 50-100 words (or more, if you like) what you hope to gain from this experience. It could be anything from “I simply want to deepen my own practice” to “I want to teach meditation as part of my professional work.”*

How do you anticipate applying what you will learn in this program, as far as you know now? Please let us know in 50-100 words or more, if you like.*

Note: Meditation is not for everyone. For example, people with PTSD or a history of trauma may actually intensify their suffering rather than relieve it. Please let us know if any of these apply to you. These are definitely not reasons to reject your application but will help us to get to know you better to ascertain if this program will serve you. Please check any or all that apply.*

I am in recovery
I have been diagnosed with PTSD or suspect that I suffer from it.
I am under care of psychiatric professionals.
Not applicable.

There is a mental or physical health condition not on this list that I would like to make you aware of:

If you are in recovery, for how long?

Please list any current or relevant mental health diagnoses:

Please add anything else you would like us to know about you.*

Will you be using this course to obtain CCEU’s for ICF re-certification?*

Yes
No

Will you be using this course for re-certification as a yoga teacher via Yoga Alliance?*

Yes
No

Will you be using this course for credit in any other association? If so, please let us know which:

How did you hear about this course?*

Open Heart Project website
Open Heart Project email
Facebook
Instagram
Program Graduate
Friend
A talk by Susan
A talk by Jenna
Can't remember

Note: Attendance at all classes and check-ins is mandatory. If necessary, one class or check-in may be missed, but it may not be the opening session, class one or class ten. Please check the following. If I’m accepted, I certify that I can attend all of the classes and check-ins below (one class or check-in can be missed, although not the Opening Session, Class one or Class ten).*

Note: Your full attention and participation is required at each class and check-in. If accepted, I will be able to give my full attention to the classes and check-ins (I will not be driving, walking, or otherwise engaged in a separate activity).*

Agree
Disagree

Note: It is the student's responsibility to ensure adequate technology and bandwidth to attend all classes and check-ins, even if traveling. I possess the technology and bandwidth to attend video teleclasses and agree to show up via webcam for each session.*

Agree
Disagree

I agree not to teach others what I am learning in this program until it is completed, my own practice is stable, and I have successfully fulfilled all the requirements.*

Agree
Disagree

I understand that successful completion of this program is based on various factors including, but not limited to, mandatory attendance, class participation, written homework, and demonstrating personal understanding of the material. If I fail to meet these requirements, I acknowledge that I am not guaranteed a certificate.*

Agree
Disagree

Questions?

Once accepted, applicants must pay within 10 days to secure their spot in the program. If you have any questions about this application or need clarification about the course, we are here to help! Please contact us at lisa@openheartproject.com.