Registration Form - Yoga for the Special Child 95H Certification Program - Part 1 - IN PERSON Program  Dates October 24-29, 2022
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Where did you hear about the training?  Did one of our program coordinators encourage you to sign up? Or from YSC office/website/social media pages.  Please list the sites/names for us. Thank you!   *
Required
Please tell us the coordinators name below. If you found us through another social media profile or page, please tell us who or where. Example: Yogaville, IYI, IAYT, YA, Thank you!   *
First Name *
Last Name *
Type your full name EXACTLY how you want it to appear on the Certificate/Credit Hours (whichever applies) *
We will copy and paste from here, so please write capitals and lower case letters the way you want it to be printed on credit hours. Please be diligent here!  Thanks!
Email
I am aware of the dates for the program are 24-29th October 2022.  9:00 am - 5:00 PM daily with a one hour break for lunch.   *
By registering for this program I agree not to copy materials, share videos or any links that are shared with me by Yoga For The Special Child®, LLC.  I understand that these are copyrighted materials and are shared with me as a registered program participant at the sole discretion of Yoga For The Special Child. Please sign your name below to acknowledge that you will NOT share the materials, or photos and  will not do any recordings of the training. *
Birth Date *
Occupation *
Gender *
Hatha Yoga Level *
Do you have a child with additional or complex needs ? Do you yourself have any additional needs or physical disability?  *
Yes/No  (if yes, please explain below)
Postal  Address *
Please include: Full mailing address, city, state & zip
Country *
Phone *
Emergency contact *
Please fill in name & number of contact
Have you ever attended our Yoga for the Special Child Part 1 Program before? (if so, please write city, state, date and name of teacher you took the training from) *
Payment information *
Required
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 *
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