Power Yoga Registration May 8 – June 26, 2019 This is an 8-week class. *Indicates required fields. About Me Name* First Middle Last Email* Phone* Alternate Phone Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I am a care-giver: at home at work at RM+V in the community How would you describe your experience with yoga? Beginner Intermediate Experienced Are you 18 or older?* Yes No About my accompanying senior I will be bringing the following senior for whom I provide care: First Middle Last Scope of Senior Activities By registering for this class, I understand that my accompanying senior will be able to participate in group activities and that elder care services are not included. Questions or Concerns? Please share with us any concerns or questions you may have about your senior participating in group activities. How did you hear about us? Word of mouth Healthcare Provider Newspaper Social Media Television Website Other Please check all that apply. * Applicant's Signature Date Captcha Please enter the code you see (prevents spam) Name This field is for validation purposes and should be left unchanged.