Chakra Intensive 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:                         Time of Birth (exact):

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 $850 for the retreat.

(   )  If prior to August 6 - Early Registration in full is $750.00

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

Will you need assistance with housing?________  Will you have a car while you are here?

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

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