Text Box: Registration
 

 


REGISTRATION FORM

 

 

Family Name: ____________________________†††††††††††† First Name: _______________________________

 

Date of Birth: MM/DD/YY___________________

 

Address: __________________________________________________________________________

 

City: ________________ Postal Code: _________

 

Phone / Cell: ______________________________††††††††††††††††††††††† Email: ___________________________________

 

Emergency contact:

 

Name: ___________________________________††††††††††††††††††††††† Relation: _________________________________

 

Phone / Cell: ______________________________

 

 

PS Select:

Yoga session [ ] ††††††††††††††††††††††††Yoga Workshop ††[ ]††††††††††††††††††† Therapy Session [ ]    

Private Session [ ]†† †††††††††††††††††††Group Session [ ]††††† ††††††††††††††††††Corporate Workshop [ ]

200 Hrs ˇ††††††††††††††††††††††††††††††† 500 Hrs [ ]††††††††††††††††††††† †††††††††††Teacherís Training [ ]

Membership ˇ††††††††††††††††††††††††† Yoga Retreat [ ]†† ††††††††††††††††††††† Yoga Tour[ ]

 

Payment:

Deposit ††[ ]†††††††    Full Payment†† [ ]†††††††††††† By Cash†† [ ]††††     Cheque†† [ ]

 

Amount: ______________________________

 

Signature: ____________________________ ††††††††††††††††††††††††††††† Name:_____________________________________

(PSPrint your name)

 


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