Congratulations on registering for
the Brain Longevity® Therapy Training in Washington, DC.
Please respond to all the questions so we can be better prepared to host you. Please complete within 3 days of receiving this link.

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* 1. What is Your First and Last Name?

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* 2. Are You

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* 3. What is Your Address? Please Make Sure to Include City, State and Zip Code.

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* 4. What is Your Phone Number and Personal e-mail?

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* 5. What is Your Profession?

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* 6. Did you apply for CEU's?

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* 7. What is Your Age?

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* 8. How Did You Hear About the Brain Longevity Therapy Training? (Please mark all that apply)

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* 9. Have You Ever Lectured or Taught Adults Professionally?

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* 10. What is Your Dietary Preference (Please mark all that apply)

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* 11. Severe Dietary Allergies. 
Please note we are unable to confirm strict observance to severe dietary allergies on the part of the catering company. However, we are happy to pass this information to the caterer.

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* 12. Are You a Psychologist / Therapist?
(Please mark Yes/No with an X)

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* 13. Are You a Certified Yoga Therapist?
(Please mark Yes/No with an X)

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* 14. Are You a Certified Yoga Teacher?
(Please mark Yes/No with an X)

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* 15. Topic: Nutrition - Personal Experience

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* 16. Topic: Nutrition - Professional Experience

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* 17. New Tools

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* 18. Topic: Physical Exercise - Personal Experience

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* 19. Topic: Physical Exercise - Professional Experience

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* 20. Topic: Mental Exercise

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* 21. Topic: Spiritual Fitness

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* 22. Please add anything else that would help us know you better in preparation for this course.
We look forward to meeting you and working with you.

Thank you for your time. 
We look forward to meeting you soon.
Kirti Khalsa, Program Manager

For further information, please email:
Julie@alzheimersprevention.org

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