Under 18 Specialized Registration Form

Parent Details

First Name *

Last Name *

Email *

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Kid Details

Full Name

Gender *

Date of Birth *

Does your child have any health issues? *

If Yes, Please give details: *

Is your child on medication? *

If Yes, Please give details: *

Does your child have any allergies that you know about? *

If Yes, Please give details: *

Are there any cultural factors that need to be considered? *

If Yes, Please give details: *

What comforts your child? *

Any other information that we need to be aware of: *

Program Details

Yoga Program *

Has your child practised yoga before? *

What are your goals for your child within this yoga program? *

General wellbeingStress reliefConcentrationCoordinationMemorySpeechBoost self-confidenceAnxietyDepressionSelf-injuryTraumaADHD-relatedDyslexia-relatedBehaviour-related

Select all that apply

Additional details about goals selected above *

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