Oak Park Yoga 327 Chicago Ave. Oak Park, IL 60302
Registration Form
Student’s Name _____________________________
Entering Grade (2009-10 school year)_______
Parent’s Name__________________________
Date and Amount of Payment __________________
(6 classes - $168, 12 classes - $312, additional classes @ $27 per class, all 18 classes - $432)
Payment Type: Check or cash receipt Number_________________
Charge Card: MC ___ Visa___
#_________________________ 3 digit security code from back___
(Above numers only needed if charge is not processed in person)
E-mail address
______________________________
Emergency phone number
______________________________
Special concerns or
requests______________________
1st – 4th Grade CAMP DATES (check chosen dates)
Week Month Tues Wed Thurs Week Month Tues Wed Thurs
#1 June 23___ 24___ 25___ #4 July 14___ 15___ 16___
#2 July 30___ 1___ 2___ #5 21___ 22___ 23___
#3 7 ___ 8___ 9___ #6 28___ 29___ 30___