Kundalini Yoga Retreat Registration Form

Please print this form and forward it along with your payment to:

7Centers Yoga Arts, 2115 Mountain Road, Sedona, AZ. 86336 or email to: yoga@7centers.com

Name: ____________________________________________________

Date of Birth:   _______________                 Sex:   _____________

Place of Birth: ______________________________

*Street Address and State: ____________________________________________________

____________________________________________________

Zip Code:  ___________

Telephone:    _____________________    Email:  ______________________________

*We will be sending you an orientation letter - let us know if you need it mailed to a particular address. Otherwise we will contact you by e-mail.

Credit Card #: (Visa/Mastercard):   ____________________________________________

Exp. Date :  ___________________________________

Signature code on the back of your card__________

(  ) Enclosed is the full amount of $575 for the retreat.

If you are paying by check please make it payable to Mystis, Inc., our non-profit organization.

Is there anything you would like for us to know about your health or personal history?