Registration Form - Yoga for the Special Child Basic Program - 2019
Please fill in all fields
First Name *
Your answer
Last Name *
Your answer
Birth Date *
Your answer
Occupation *
Your answer
Gender *
Hatha Yoga Level *
Do you have a child that is physically challenged? *
Yes/No (if yes, please explain below)
Your answer
Would you be interested on having you child evaluated during the program? (we have a session with kids on days 3,4 or 5 at 3pm) *
Yes/No (if yes, please explain below)
Your answer
Mailing Address *
Please include: Full address, city & zip
Your answer
Country *
Your answer
Phone *
Your answer
Email *
Your answer
Emergency contact *
Please fill in name & number of contact
Your answer
Have you attended a Yoga for the Special Child program before? *
If you have attended, please state where & when
Your answer
I wish to attend the program in *
please state, city/country
Your answer
I wish to attend the program commencing *
please fill in date.
MM
/
DD
/
YYYY
Current Total Payment
Your answer
Payment *
Payment amount *
The teacher training experience can be a time of deep emotional connection for some people. Though this process is healing, it can also be stressful. If you have any history of mental illness i.e. depression, anxiety, schizophrenia, bipolar disorder, posttraumatic stress disorder or any form of psychosis, it would be very helpful for your teacher to know in order to be sensitive to your needs. If you are taking medications or have been hospitalized for any of these conditions please describe below. *
Your answer
Please list any prescription medications
Your answer
Terms and Conditions
1. To confirm your reservation, please make full payment ($1080 or $980 for early bird) or a minimum deposit of $300 . Payment in full must be received 30 days prior to program start date. Please email your name to renata@specialyoga.com if you want a paypal invoice or mail your check to Yoga for the Special Child 232 Hidden Bay Dr #503 Osprey Fl 34229

2. All payments made are non-refundable, unless the program is canceled by Yoga For The Special Child (YSC), in which event you will receive a full refund. However YSC shall not be responsible for refunding airline tickets or hotels under any circumstances. Please make sure to call Renata 941-320-9290 to confirm the program is a go before making any travel arrangements.

3. If registrant cancels 10 or more days before the program start date, by way of YSC receiving notice from registrant within that time, the sum of $90 shall be deducted by YSC as an expense of administration. Any balance paid in excess of $90 shall be held for registrant without interest, and may be applied by registrant to another program within one year of cancellation. If not applied within one year, all monies paid shall be forfeited.

4. If registrant cancels less than 10 days before the program start date, the sum of $300 shall be deducted by YSC as an expense of administration. Any balance paid in excess of $300 shall be held by YSC without interest, and may be applied by registrant to another program within one year of cancellation. If not applied within one year, all monies paid shall be forfeited.

5. By signing below, I, the registrant, agree to these terms and conditions.

Full Name *
Your answer
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service