Residential Karma Yoga Program Application Program Term*June 12th - August 15thAugust 27th - October 15thName* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth MM DD YYYY Gender[Select]FemaleMaleOtherCitizenship*Are you legally able to work in Canada?*ExperienceHave you previously resided at either The Salt Spring Centre of Yoga or Mount Madonna Centre?NoYes - Salt Spring CentreYes - Mount Madonna CentreFrom To Do you have experience in any of the following? Housekeeping Kitchen Farming/Gardening Landscaping Maintenance Office Describe your relevant skills and experience in each of the above areas you checked.Medical HistoryIt is important that we know about your health status. Please answer the following as accurately as you can. All information is confidential.Do you have any physical limitations that might affect your ability to work? If yes, please describe in detail:*Have you experienced any of the following conditions in the past two years? Please check any that apply or select "none of the above".* Diabetes – Type 1 Diabetes – Type 2 Coronary Heart Disease Epilepsy Chronic Fatigue Syndrome/ Fibromyalgia Neurological Disorders & Symptoms (nerve pain, numbness, tingling) Cancer Depression Bipolar Disorder OCD or other anxiety disorder Seizures Chemical Dependency (nicotine, alcohol or other drugs) Eating Disorders (anorexia, bulimia) None of the above If you do have a current medical condition, please describe how it is being managed, including forms of treatment and all prescribed medication:Are you currently pregnant? Yes No Please list any allergies, indicating the severity of the allergy and any precautionary measures you take (If none, state "N/A")*Do you have any special dietary needs? Do you foresee any difficulty in adopting the lacto-vegetarian diet described in the Centre Guidelines?view the Centre GuidelinesDo you currently smoke? Yes No Have you suffered any severe shock or chronic stress in the past year (e.g. bereavement, divorce, loss of job). If yes, please explain. If no, state "N/A":Are there any other mental or physical health concerns we should be aware of?Other InformationHave you ever been convicted of a crime (other than moving violations)?* Yes No Are there any other comments you'd like to add to your application?In the event that the program is full, would you like to be added to the waiting list in case of cancellations? This would mean acceptance to the program at very short notice. Yes No Please attach your resume (.doc, .docx or.pdf files only).*Accepted file types: doc, docx, pdf.AcknowledgementsYoga Instruction and Liability Waiver and Release* I have read and understood the Yoga Instruction and Liability Waiver and Release and agree to its terms. Cancellation Policy* I have read the Salt Spring Centre's Cancellation Policy and agree to its terms. Centre Guidelines* I have read and agree to the Centre's Guidelines.