~ Please make check payable to Heart Center Yoga ~
Mail To: Heart Center Yoga, 459 Central Ave., Highland Park, IL 60035

                            Name(s) of Adult(s)                                                                                                                                  

                            Number of Children attending:               Name(s)/Age(s)                                                                         

                            Address                                                                                                                                                    

                            City / State                                                                          Phone Number                                              

                            Emergency Number w/Name (for child attendees)                                                                                   

                            Email Address                                                                                                                                          

                            Name and Date of Workshop                                                                                                                    

                            Amount Enclosed  $