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 1.      Name                                     :
 2.      Place / Date of Birth                    :
 3.      Home Address                             :
         Postal Code                              :
 4.      Home Telephone                           :
         Mobile No.                               :
 5.      Gender                                   :
 6.      Job                                      :
 7.      Email Address                            :
 8.      Would you like to be on our                       Yes          No
         mailing list                             :
 9.      Would you like to receive our                     Yes          No
         newsletter                               :
 10.     Health Concerns                          :
 11.     Any Injury                               :
 12.     Have you practiced yoga                            Yes       No
         before?                                       If yes, for How Long?
 13.     Are you teaching Yoga?                             Yes       No
                                                       If yes, for How Long?
 14.     Are you teaching Iyengar yoga?                     Yes       No
                                                       If yes, for How Long?
 15.     Where did you hear about our :
 16.     Yoga workshop, please mark your choice:

                                        1 Class Pass (Rp. 50.000)
                                        4 Class Pass + Kids Yoga Class (Rp. 200.000)
                                        Iyengar Yoga Advance Class (Rp. 80.000)

Please make payment to Riana Andyanto Singgih, BCA Cab Permata Hijau, A/C No,178 121 4901 and send
together with the completed registration form to Fax: (62‐21) 739 6847 or send it to Iyengar Yoga Centre
Indonesia, Ruko Simprug Galleri 10W, Jl.Teuku Nyak Arif, Jakarta 12220.

Liability Waiver Agreement
I                                      , understand that yoga includes physical movements as well as an opportunity for
relaxation, stress re-education and relief of muscular tension. As in the case of any physical activity, the risk of injury is
always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust
the posture and ask for support from the teacher.
Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I affirm that I alone am responsible to
decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter
may have against Yoga8Light.
Workshop Policy
Full payment is required to reserve a space in workshops. Full refunds less 5% cancellation fee are given for cancellations
made 3 weeks or more prior to workshop start date. Full refund made less than 3 weeks and at least 7 days prior to
workshop start date a 50% refund will be given. No credits or refunds will be given less than 7 days prior to workshop
start date for any reason. Iyengar Yoga Centre Indonesia is not responsible for any and all costs incurred for travel
arrangements or accommodations related to this event..

Name & Signature of Student                                      Date

                    Ruko Simprug Galleri 10W, Jl. Teuku Nyak Arif, Jakarta 12220
                       Tel: (62‐21) 739 6930, 739 6904, Fax: (62‐21) 739 6847
           Email: |

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