First Name:

Last Name:

Studio Affiliation:

Address:

City:

State:     Zip:

Phone Numbers – Work: Home:  
Cell: Fax:

E-mail Address:

Website:

Please list all current certifications and the certifying organization:

Pilates 

Gyrotonic

Yoga   

Feldenkrais   

Other   

Check the Continuing Education Organizations which you belong to: 

PMA  Stott    Polestar   PMI ACE    AFAA   
NCSM    ACSM     Namasta     Yoga Alliance   Other: 

University degree:

Are you a continuing education provider? Please list organizations you are registered with:

Biographical information - Please limit to 35 words for the catalog:

You may include a longer biography for the website:

Only Submit One Presenter Application - You may submit multiple Course Applications (below)