Yoga Student Class Registration Form:

IRIS Participants


Please fill out the form below for registration using your IRIS funding.

IRIS Consultants please contact Iris Mickey at with Preauthorization and payment information in addition to registration.

1. Student Name: *
1. Student Name:
2. Student Address: *
2. Student Address:
3. Student Phone contact: *
3. Student Phone contact:
7. IRIS Consultant Phone contact: *
7. IRIS Consultant Phone contact:
9. Is this student most appropriate for a chair yoga class or a mat yoga class? *
The mat yoga class moves up and down from the floor and includes many standing poses? (Please choose the class appropriate for the student)
What will the caregivers role be in assisting the student? ie., Emotional/Behavioral support or physical support
16. What is the primary goal for the students program? *
Please choose and check the appropriate boxes from the primary yoga objectives below or add your own.
18. Did someone other than the participant fill out this form? *
If answered yes to #18