Name of Student:        

Child's Age:      


Parent or Guardian Name:                                      

Address:        
 City:         
Zip:           

Phone:        Email: 

Emergency Contact:
Name:      Phone:

Sign me up for: (select all that apply:)

WINTER 2012:

Children's Classes: $95
Tuesdays, Jan. 10th - March 6th for 8 weeks , 4:30-5:30 PM  for 5-10 yr olds @ May Memorial on E. Genessee St. in Syracuse 
Thursdays, January 12th - March 8th for 8 wks, 4:30-5:30,  for 4-7 yr olds @ CNY Yoga  101 First St. Liverpool
Thursdays, January 12th - March 8th for 8 wks, 5:45-6:45pm,  for 8-11 yr olds @ CNY Yoga  101 First St. Liverpool

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Names of Family Class Attendees: (if applicable)