Registration Form - CPD Asana Pranayama and Meditation

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Registration Form - CPD Asana Pranayama and Meditation - October 14-17, 2021

Please fill in all fields that applies to 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!

I am aware this is a live streaming program and I will organize my schedule to be available at dates and times of training from Thursday- Sunday 16:30-21:00 (India Time Zone) - Thursday to Sunday 07-11:30am EST *

Yes

Please share with us how you heard about our course. Newsletter, social media- Facebook, Instagram, person. *

I am aware of the dates for the program from October 14-17, 2021 *

Yes

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. *

Birth Date *

Occupation *

Gender *

Hatha Yoga Level *

Beginner

Intermediate

Advanced

Do you have a child that is physically challenged? *

Yes/No (if yes, please explain below)

Mailing Address *

Please include: Full 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 *

Paypal (400Euros/US$450)

Check (US funds only US$430)

I would like to wire the payment (400 Euros or US$450)

Zelle (430$)

I will make my payment directly to IYI India (Integral Yoga Coimbatore)

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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