YAMUNA® BODY ROLLING
CERTIFICATION REGISTRATION INSTRUCTIONS
Registration Requirements
3 Ways To Register
Fax: completed registration form to 212–633-1690
E-mail: education@yamunabodyrolling.com
Mail: send the completed registration form with your check, money order or credit card information to:
YZ Studio, Attn: Isabel Eisen, 333 Hudson St., Suite 505, New York NY 10013
(Check or money order should be made payable to: Yamuna Studio Inc.)
 50% Tuition is required at time of registration. Remaining 50% will be collected 1 week before course start date
 A registration form is required for each training.
 DISCOUNT:$75.00 off when payment is received in full 6 weeks prior to course start date
*Not for Recertification, Intensive, repeats, or any training taken with Yamuna
 You are not registered unless you receive a registration confirmation email response.
Tuition and Fees (Note: Trainings abroad and with Yamuna herself may have a different rate.)
Course Title
YBR® Experiential Anatomy (formerly Phase 1)
Tuition & Fee
$620 *not including materials fees
YBR® Phase 2 (Phase 2A & Phase 2B)
$1,250 *not including materials fees
YBR® Intensive (Phase 1 & Phase 2)
$1,650 *not including materials fees
YBR® Hands-On Table Treatment
$1,320 *bring table (or let us know)
Yamuna® Yoga
$1,000
Body Logic (BL) Week 1 – Week 8
$1,500 per week, Next session begins in 2015/2016
Recertification 3 day
$300 DUE IN FULL AT TIME OF REGISTRATION
Face Ball Certification
$1,000
Foot Fitness Certification Part 1
$800
Foot Fitness Certification Part 2
$1,000
Foot Fitness Certification Part 1 (Milan)
$1,200
Breath Work Certification
$1,000
Please request special application forms for trainings in Alicante and London.
Refunds and Cancellation
Yamuna Studio cancellation of a class or workshop:
 Your choice of full refund or Apply 100% tuition to another class.
 Yamuna studio is not liable for travel and accommodation expenses.
 Make sure that all of your arrangements are refundable or changeable or both.
Student cancellations:
 6 weeks or more prior to class: 100% Tuition Refund.
 2-4 weeks notice prior to class: 50% Tuition Refund.
 4-14 days notice prior to class: 25% Tuition Refund.
 3 days or less prior to class: No Refund.
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*Cases of extreme emergency will be reviewed on an individual basis.
*All refunds may be applied to another class which must be taken within 1 calendar year of cancelled class.
*Cancellations must be received in writing.
*No discounts for trainings taken with Yamuna
April 2014 IE
YZ Studio, 333 Hudson St., Suite 505, New York, NY 10013 · Tel: 212.367.9570 · Fax 212.633.1690
www.yamunabodyrolling.com education@yamunabodyrolling.com
YAMUNA® BODY ROLLING
CERTIFICATION REGISTRATION FORM
Please answer each question clearly and completely. Type or print in ink. Read carefully and follow all directions. Please
provide your signature and date you signed the document as well. Use the TAB key on the keyboard or your mouse to
move between shaded fields.
Section A: General Information
First Name
DATE:
Last Name
________
Middle Name
Date of Birth
Street Address
APT. #
Daytime Phone Number
City, State, Zip
Country (if other than U.S.A.)
Evening Phone Number
Email Address
Occupation
Section B: Class & Workshop you are registering for
Course Title
Location
Date
Tuition & Fee
YBR® Experiential Anatomy/Phase 1
$620
YBR® Phase 2 (Phase 2A & 2B)
$1,250
YBR® Intensive
(Phase 1 & Phase 2)
$1,650
YBR® Hands-On Table Treatment
$1,320
Yamuna® Yoga
$1,000
Body Logic (week
)
$1,500 / week
Recertification 3 day
$300
Face Ball Certification
$1,000
Foot Fitness Part 1
$800
Foot Fitness Part 2
$1,000
Foot Fitness Certification Part 1 (Milan)
$1,200
Breath Work Certification
$1,000
Tuition & Fee Total
(Repeat or early registration)
Discount
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Total
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April 2014 IE
YZ Studio, 333 Hudson St., Suite 505, New York, NY 10013 · Tel: 212.367.9570 · Fax 212.633.1690
www.yamunabodyrolling.com education@yamunabodyrolling.com
Section C: Payment Method

Check (payable to Yamuna Studio Inc.)
MasterCard
Visa
Money order (payable to Yamuna Studio Inc.)
(Note: we no longer accept American Express)
Credit Card Number
Exp. Date and security code
Print card holder’s name as it appears on credit card
Signature
Date
Section D: Short Health Questionnaire
Health Summary – Please check all that apply:
spinal surgeries / disorders  list:
muscle / joint pain  list:
muscle / bone injuries  list:
sprains / strains  list:
cesarians – please list dates if “yes” to cesarians 
high blood pressure
low blood pressure
diabetes prosthesis
asthma / lung problems
Are you currently under a physician’s care?
If “Yes,” please explain.
pregnancies
No
Yes
Your physician’s name 
Are you pregnant now?
If “Yes,” how many weeks?
No
Yes,
weeks
Please list all medications and any supplements you are taking.
Do you have any medical / health conditions which will prevent your full participation in the class / workshop that you
are registering for? If “Yes,” please explain.
Section E: Please give the name of a person, either a relative or friend who lives in the United States, who can be
contacted in the case of emergency.
Last Name
First Name
Street Address
City
Day Time Phone Number
State
Zip code
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Country
April 2014 IE
YZ Studio, 333 Hudson St., Suite 505, New York, NY 10013 · Tel: 212.367.9570 · Fax 212.633.1690
www.yamunabodyrolling.com education@yamunabodyrolling.com
Agreement of Release and Waiver of Liability
Please read, sign and return this waiver along with your registration form and health questionnaire.
I,
(Please print your name), hereby agree to the following:
1) That I am participating in YBR® Practitioner training classes or YBR® Workshops offered by Yamuna Studio,
Inc. during which I will receive information and instruction about YBR® . I recognize that this fitness
program involves physical contact and requires physical exertion which may be strenuous and may cause
physical injury, and I am fully aware of the risks and hazards involved.
2) I understand that it is my responsibility to consult with a physician prior to and regarding my participation in
the YBR® training classes or workshops. I represent and warrant that I am physically fit and I have no
medical condition which would prevent my full participation
3) In consideration for being permitted to participate in YBR® training classes or workshops, I agree to assume
full responsibility for any risks, injuries or damages, known or unknown which I might incur as a result of
participating in the program.
4) I understand that I have the right and duty to inspect the mats, facilities and equipment to be used and if I
believe that anything is unsafe or beyond my capability I will immediately advise the instructor or
supervisor of such condition(s) and refuse to participate.
5) In further consideration of being permitted to participate in the YBR® training classes, programs or
workshops, I knowingly, voluntarily and expressly waive any claim I may have against Yamuna Studio, Inc.,
its officers, instructors or employees for injury or damages that I may sustain as a result of participating in
the program.
6) I, my heirs or legal representatives foreseer release, waive, discharge, and covenant not to sue Yamuna
Studio, Inc. its officers, instructors or employees for any injury or death caused by their negligence or other
acts.
7) I understand that until I complete all of the YBR® requirements I am not a certified practitioner and will not
teach or use the work with my clients.
I have read the above release and waiver of liability and fully understand its contents as well as the
Refund/Cancellation Policies. I voluntarily agree to the terms and conditions stated above.
Signature:
Please print your name:
Date:
________________
________________________________
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April 2014 IE
YZ Studio, 333 Hudson St., Suite 505, New York, NY 10013 · Tel: 212.367.9570 · Fax 212.633.1690
www.yamunabodyrolling.com education@yamunabodyrolling.com
On a separate sheet of the paper, please answer the following questions, limiting your answers to one paragraph per question. Type or
print in ink.
1.
2.
3.
4.
Assess your strengths and weaknesses as a student and as a future health professional.
What are your reasons for choosing to learn Yamuna® Body Rolling?
Please describe in general your existing clientele, if you have one.
Please describe any previous hands on experience that you might have.
Note: it is a requirement that you experience classes from a Certified YBR® practitioner before you enter the program. Please submit
documentation of those classes. If you have any difficulty with taking classes prior to entering our certification classes please contact
Isabel Eisen at 212.367.9570 or education@yamunabodyrolling.com. We will be happy to assist you in fulfilling this pre-requisite.
Have you ever applied to or attended YBR classes previously?
list date of Application or date of enrollment.
No
Yes
If “Yes,” please
Have you ever been convicted of a felony or misdemeanor, other than minor
traffic offenses?
If “Yes,” please describe.
No
Yes
Modalities you are certified / licensed in and the date you received your
certificate / license:
How did you learn about Yamuna® Body Rolling?
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Thank you!
April 2014 IE
YZ Studio, 333 Hudson St., Suite 505, New York, NY 10013 · Tel: 212.367.9570 · Fax 212.633.1690
www.yamunabodyrolling.com education@yamunabodyrolling.com