Vancouver Pilates Centre

TEACHER EDUCATION PROGRAM

APPLICATION FORM – Theory Modules

Print this page and fill out to mail us.

Name: ____________________________

Mailing Address:_____________________________________________________

Phone (home)_____________ (cell) ______________ (work) ________________

Fax _______________ e-mail ________________________

Please indicate below which Certificate Program you are applying for, if any.

Theory Modules are open to advanced students and Pilates teachers who meet the prerequisites. Certificates will be provided upon successful completion of all certificate requirements.

___Dianne Miller Pilates Comprehensive Teaching Certificates

____ Level 1 [Pilates Mat Work and Universal Reformer]
____ Level 2 [All Pilates Apparatus]

___Dianne Miller Pilates Continuing Education Certificates

____ Continuing Education Certificate [Pilates Mat Work and Universal Reformer]
____ Continuing Education Certificate [All Pilates Apparatus]

___I am not applying for a certificate program at this time

To complete your application, please include a brief description of your relevant experience, including:

• Pilates training (list teachers, dates, mat/apparatus, etc.)
• Pilates teaching experience (provide copy of previous Pilates certificates, if applicable)
• Related background (movement training, teaching experience, etc.)
• Relevant formal education

Please forward your completed application, including deposit of $400+$48 (HST) per module to:

Dianne Miller Pilates Teacher Education Program
Vancouver Pilates Centre
719 West 16th Avenue,
Vancouver,
B.C.
Canada V5Z 1S8

Application deadline for 2010-11 Theory Modules: August 7, 2010

Applications will be reviewed and may require an interview and/or demonstration of prerequisite exercises.

All applicants will be notified by telephone or email regarding acceptance.

 

PHYSICAL HISTORY QUESTIONNAIRE

Name: __________________________________

Birth date: _________________ Height: __________ Weight: ____________

Sex: F M Occupation: ___________________________

1. Current Physical Activities
   (Please specify frequency, duration, and professional or recreational standing)_____________________________________________________________
2. Past Physical Activities (if different from above) _____________________________________________________________

Do you have now, or have you had within the past 3 years:	NO	YES	If yes, please explain
Difficulty with physical exercise?
Advice from a physician not to exercise?
Muscle, joint, or spinal disorder that could be aggravated by exercise?
History of heart problems?
History of lung problems?
High or low blood pressure?
A chronic illness?
Recent surgery (within the past 6 mo.)?
Diabetes?
Glaucoma?
Are you now, or have you been pregnant within the past 3 months?
Are you presently taking any medication which may affect, or be affected by physical activity?
Please give a brief description of any past or current injuries, structural alignment problems, or medical conditions not specified above

_____________________________________________________________

_____________________________________________________________

I hereby verify, that to the best of my knowledge, the above information is correct.
SIGNATURE: ___________________________ DATE:__________________