Name

Date

Address

Telephone (home)

Telephone (work)

Email

Date of Birth

Present Occupation

1. Experience with the Alexander Technique: List the teachers you have studied with, the approximate dates you studied with them and the number of lessons you have had with each.

2. Detail your educational background:

3. Describe your previous work experience:

4. List any experiences you have had in related fields:

5. Describe any special interests and hobbies:

6. Give your medical history (hospitalizations, operations, physical disabilities or injuries, medicines you are currently taking and any current health problems):

7. Explain your reasons for wanting to become an Alexander teacher.