Registration Form - YOGA FOR THE SPECIAL CHILD® CE PROGRAM Arthritis and Scleroderma

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Registration Form - YOGA FOR THE SPECIAL CHILD® CE PROGRAM Arthritis and Scleroderma - Chicago, IL September 20-22, 2019

Please fill in all fields

Email *

Name *

Birth Date *

Occupation *

Address

Please include: Full address, city & zip

Country *

Phone *

Do you have arthritis or scleroderma? Do you know someone with either who would like to volunteer in our program? *

Yes/No (if yes, please explain below)

Hatha Yoga Level *

Beginner

Intermediate

Advanced

Email *

Emergency contact *

Please fill in name & number of contact

Please list your program prerequisite: Yoga teacher with 1 year experience teaching special population, OR Health Professional/Special Education with 1 year minimum consistent personal yoga practice, OR attended Yoga for the Special Child Basic 1 Program *

CEU Documentation needed

Yoga Alliance

International Association of Yoga Therapists

American Occupational Therapy Association

Nevada Physical Therapy Board

Other

None

Other:

Clear selection

Payment *

Check ($530)

Deposit ($180)

Early Bird Discount ($480) by July 31, 2019

Licensed Practitioner Discount ($477)

Credit Card, see below

Other

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 $180. 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. You may 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. You may also pay online here: https://www.5keysyoga.com/ysc-payment.html. Please be aware that there is a 3% fee added to all credit card purchases.

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 $80 shall be deducted by YSC as an expense of administration. Any balance paid in excess of $50 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 *

Date *

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