New Student Movement Registration Form — Rosen Method Open Center

New Student Rosen Method Movement Registration Form

Your answers to the registration form questions are confidential and will only be seen by teachers and staff.

Name

First Name

Last Name

For which movement intensive/workshop are you registering?

Phone

(###)

###

####

Date of Birth

YYYY

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Emergency Contact

First Name

Last Name

Emergency contact's relationship to you

Emergency contact's phone number

(###)

###

####

How did you first learn about Rosen Method Movement?

Please list when, where, and any teachers you've studied with.

Do you have any experience with body awareness practices?

Please specify.

What degrees, licenses, and/or certifications do you hold?

What is your purpose in taking this Rosen Method Movement intensive/training?

What is your family situation?

Single/Married/Partnered; children – ages?

What support do you have in your life?

Friends, work, etc.

Please tell us about your present physical and emotional state.

Is there anything we should know about your physical health?

Illnesses, injuries, accidents, surgeries?

Do you have any physical limitations?

If you have any questions regarding personal capabilities in being able to participate in the intensive, please speak to us directly.

Are you currently taking medications? If so, please list.

Is there anything else you would like us to know about you?

When being addressed, what pronouns do you prefer?

She/Her

He/Him

They/Them

Any of the above

She/They

He/They

Other (please specify in box above)

Please sign and date this registration form.

Your digital signature confirms that you have completed this form accurately and honestly, and that you have reviewed our cancellation and refund policies.

Date of signature

YYYY

Would you like to receive information about future Rosen Method Open Center events?

Yes

Please refer to the RMOC website for our cancellation/refund policy.

Attendance is required from the beginning to the end of the intensive.