Registration Form - Yoga for the Special Child Part 1 Program - IL - 2020
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First Name *
Last Name *
Name EXACTLY how you want it to appear on Certificate/Credit Hours (whichever applies) *
We will copy and paste from here, so please write caps and lower cases the way you want it to show up on credit hours.
Birth Date *
Occupation *
Gender *
Hatha Yoga Level *
Do you have a child that is physically challenged? *
Yes/No  (if yes, please explain below)
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)
Mailing Address *
Please include: Full address, city, state & zip
Country *
Phone *
Email *
Emergency contact *
Please fill in name & number of contact
Have you attended a Yoga for the Special Child program before? *
If you have attended, please state where & when
I wish to attend the program in *
Chicago, IL
I wish to attend the program commencing *
please fill in date
Current Total Payment
Payment *
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. *
Please list any prescription medications
Terms and Conditions
 1. To confirm your reservation, please make full payment or a minimum deposit of $300. Payment in full must be received 30 days prior to program start date.  Checks and money orders should be made payable to Five Keys Yoga, LLC. Mail your payment and application to us at 1818 W. Belmont Ave., Chicago, IL 60657. If you have a credit card and wish to confirm your reservation by phone, please call 1-(773)857-1763 or make the purchase online here: https://www.5keysyoga.com/ysc-payment.html.  Please note, there is a 3% processing fee on all purchases made by credit card.  

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.  

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 $100 shall be deducted by YSC as an expense of administration.  Any balance paid in excess of $100 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.    
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