Application - Yoga for the Special Child, 95-Hour Certification Part 2 - In-Person "*" indicates required fields Step 1 of 4 25% I am aware this program will take place in person at Integral Yoga Institute in New York City. The dates for the program are April 15-21, 2023. 9:00 AM - 5:30 PM daily with a one hour break for lunch.* Yes Personal InformationName* First Preferred Name (Nickname, Spiritual name) Last Prefered Pronouns Preferred Pronouns* Email* Phone*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country My Home and Mailing addresses are the same* Yes No Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM slash DD slash YYYY Occupation* How did you find out about this program? Check all that apply.* IYINY Website Yoga for the Special Child Website Newsletter - Integral Yoga Newsletter - Yoga for the Special Child Facebook - Integral Yoga Facebook - Yoga for the Special Child Instagram - Integral Yoga Instagram - Yoga for the Special Child Internet Search Yoga Alliance Yogaville IYI San Francisco Integral Yoga Teachers Association (IYTA) Other Your Yoga ExperienceHatha Yoga Level* Beginner Intermediate Advanced 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! Do you have a child that is physically challenged?*Yes/No (if yes, please explain below) Where did you last attend our Yoga for the Special Child Part 1 Program? (Please write city, state, date and name of teacher you took the training from)* Health and Safety InformationThe 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, post-traumatic 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:* Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Methods* Phone Email Phone & Email Emergency Contact Phone*Emergency Contact Email* AgreementsCopyright Agreement*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 acknowledge that you will NOT share the materials, or photos and will not do any recordings of the training. I have read and agree to the copyright policy.Tuition Policy*Tuition payment must accompany your application to complete your enrollment.Full payment is due before the training begins. A non-refundable deposit of $300 is required to reserve your space in the programNon-payment of tuition will result in canceled registration from the course.• Early Bird Tuition for applications received by February 15, 2023 is $1080.• Full Price Tuition for applications received after February 15, 2023, is $1180.Directions to complete registration with your tuition payment will be emailed to you after your application has been reviewed. I have read and agree to the tuition policy.Admission and Continuation Policy*Acceptance into the training program is not guaranteed, and is conditional upon the applicant meeting the basic requirements as stated in the training prerequisites. A completed application form and deposit are required to be considered for acceptance. Tuition must be paid in full before the training begins, or the student may not be admitted to join the class. If an applicant is not accepted into the program, the deposit will be refunded. If the student decides to withdraw their application before the training begins, the deposit fee is nonrefundable. Any balance paid beyond the deposit amount will be returned. After the training begins, any refund of tuition is contingent upon several factors including but not limited to: length of time in the program, reason for withdrawal or dismissal, return of training materials, intention to complete the training at a later date. Applicants acknowledge that refunds after the training begins are not guaranteed, and will be issued in accordance with the Admission and Continuation Policy as stated. I agree to the Admission and Continuation PolicyTerms and Conditions 1. To confirm your reservation, please make full payment or a minimum deposit of $300. Payment in full must be received 30 days prior to program start date. The easiest way to submit payment is online via our MindBody registration system, or through Zelle or Paypal. Checks and money orders are also accepted, and should be made payable to Integral Yoga Institute and mailed to Integral Yoga Institute attn: Gopala, 227 W. 13th St., New York, NY 10024. (US funds only) If you need an invoice, please send an email to Jayadevi at TeacherTraining@iyiny.org. 2. All payments made are non-refundable, unless the program is canceled by Yoga For The Special Child (YSC) or Integral Yoga Institute, in which event you will receive a full refund. However, YSC and IYI shall not be responsible for refunding airline tickets, hotels, or other travel/accommodation arrangements under any circumstances. 3. If registrant cancels 10 or more days before the program start date, by way of IYI/YSC receiving notice from registrant within that time, the sum of $100 shall be deducted by IYI/YSC as an expense of administration. Any balance paid in excess of $100 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 IYI/YSC as an expense of administration. Any balance paid in excess of $300 shall be held by IYI/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 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. 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. 6. By signing below, I, the registrant, agree to these terms and conditions. I agree to the terms of the Terms and ConditionsGeneral Enrollment AgreementI wish to apply as a Teacher Trainee, and I agree to assume full responsibility for any injuries to me that may occur during the training. I am in good health, and any physical illnesses or ailments are clearly stated above. I have read and agree to abide by the policies for admission and continuation of the training program. I acknowledge agreement to fulfill all my teacher training requirements to meet Integral Yoga Institute and Yoga Alliance standards in order to receive my certification. I further acknowledge that Integral Yoga Institute reserves the right to withhold certification should my efforts not meet its requirements and standards. I agree to the terms of the General Enrollment Agreement PaymentSelect payment method for application deposit: Credit or Debit Card Paypal Zelle Check Deposit Price: Credit CardPlease check if you have activated a Stripe feed for your form.After submitting this application send your $300 deposit fee via PayPal to gopala@iyiny.org. Please include your name and the Training you are applying for with your paymentAfter submitting this application send your $300 deposit fee via Zelle to gopala@iyiny.org. Please include your name and the Training you are applying for with your paymentAfter submitting this application, - Make check for $300 out to: Integral Yoga Institute Inc. - Send To: ATTN: Treasury 227 West 13th Street. New York, NY 10011 Δ
