Level 1: Aquarian Teacher Training Registration Form 2018Page 1 of 2

Student Information

Name: ______Date of Birth: ______

Spiritual Name (if applicable): ______

Street Address: ______

City: ______State: ______Zip:______

Phone (home): ______Phone (cell): ______

Email: ______Referred by: ______

Please choose a payment option (lump sum or distributed payments):

$1250 deposit required by first day of class.

Early Bird Rate paid by Oct 15 is $2800.

Early Rate paid by Dec 15 is $3000.

Regular Rate paid by First class is $3200.

Payment Plan Rate is $3500 split into 5 specified payments: $1250 by Jan 6; 4 payments of $562.50 -- on or before Feb6, Mar 6, Apr 6, & May 6. Customized payments available, contact .

Program price includes: All teacher training class days (Jan 6,7, 20,21; Feb 3,4, 24,25; Mar 10,11, 24,25;Apr 14,15, 28,29; May 12,13, 26,27; Jun 9,10), texts, study materials, White Tantric Yoga (Feb 10) fees, IKYTA Associate membership, KRI royalty fee, overnight ashram styleyogic living retreat lodging (April6-8), course administration.

Program price DOES NOT include: Class fees for the 20 Kundalini Yoga classes required for certification. Students are encouraged to take classes from many different certified Kundalini Yoga teachers to experience different teaching styles.

Circle payment type and enter amount payable in the Total Amount Payable section to the right below.(Please fill in credit card information if applicable.)

PAYMENT TYPE: Check, Cash (in person only). Visa, MC Total Amount Payable: $______

Name on Card: ______Signature: ______

Card Number: ______Expiration Date: ______

3 Digit Code on back of card: ______Zip code of billing address: ______

Page 2 of 2

Refund Policy:

Course fees are fully refundable before course begins, minus $375 Lead Trainer interview administrative processing fees. After class begins refunds will exclude initial $1250 pre-pay andwill be pro-rated by the day based on the date written withdrawal notice is received. $1250 + daily pro-rate over course attended + books/supplies + WTY and retreat costs = Full rate paid for withdrawals after course begins.

Waiver of Liability

I, the undersigned, by signing this agreement, indicate that I understand the risks inherent in practicing Yoga and hereby assume all risks incidental to such activities and waive any claim or right of action against 3HO of Arizona, Jaap Kaur/Kitty Pope (licensee), Sevak Singh &Sangeet Kaur (other trainers), 3HO International, Guru Nanak Dwara Ashram,3HO Fdn of Arizona dba Yoga Phoenix, any other program facilities or grounds utilized by the course, and officers, shareholders, contract trainers/staff, and agents of these organizations for loss, expenses, liabilities, damages, or legal fees incurred on account of any loss or injury to myself or my property incurred in connection with and/or as a result of attendance at classes conducted.

By my signature below, I acknowledge that a written description of the course content and the Kundalini Yoga Teacher Training refund policy was made available to me.

Signature: ______Date: ______

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