TEACHER EDUCATION PROGRAM
APPLICATION FORM - Certificate Programs 2008
Print this page or download the PDF Application form
Name: ____________________________
Mailing Address:_____________________________________________________
Phone (home)_____________ (cell) ______________ (work) ________________
Fax _______________ e-mail ________________________
Please indicate which Certificate Program you are applying for:
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]
To complete your application, please include the following:
1. Application form (including the physical history questionnaire on reverse)
2. Resume: Please specify your:
- 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.)
- Formal education
3. Application fee $75.00 (plus $3.75 gst)= $78.75 (non-refundable)
(payable in Canadian funds, by certified cheque or money order)
Please forward your completed application, including application fee to:
Dianne Miller Pilates Teacher Education Program
Dianne Miller Pilates Center
719 West 16th Avenue, Vancouver, B.C. Canada V5Z 1S8
2008 application deadline for Certificate Programs - January 18th, 2008
Applications will be reviewed and may require an interview and/or demonstration of prerequisite exercises.
All applicants will be notified by telephone or email on or before January 25th, 2008 regarding acceptance.
PHYSICAL HISTORY QUESTIONNAIRE
Name: __________________________________
Birth date: _________________ Height: __________ Weight: ____________
Sex: F M Occupation: ___________________________
- Current Physical Activities
(Please specify frequency, duration, and professional or recreational standing)_____________________________________________________________ - 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:__________________