Yoga and Relaxation
ORDER FORM
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Name (Last) (First)
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Phone office/home cell
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Email Address (for confirmation of your registration)
Class date Class time Price (Write amount* or "0" for prepaid. If package, please specify package by letter**)
/ / AM
PM Package __ $__________
/ / AM
PM Package __ $__________
/ / AM
PM Package __ $__________
Total amount: $ ___________
* Regular 1-hour class: $22; 1/2-hour class: $12
**Package A: Five 1-hour classes for $95
Package B: Twelve 1-hour classes for $216
Package C: Bring a friend and pay only $33 for both
Package D: Bring 2 or more friends (up to 5) and pay only $15 per person
Package E: Ten express yoga or relaxation classes for $100
Package I (Introductory): Two classes for $25 (first-time students only)
Payment Type: ____ AMEX _____VISA_____MC
Authorized Signature__________________________________________
Card Number________________________________________________
*CCV#_______________________Expiration Date_________________
*CCV#: The 3-digit credit card validation number is located on the back of the card. AMEX users: the 4-digit credit card validation number is located on the front of the card.
To maximize the benefits of the class, please wear loose comfortable clothing.
No admissions after class starts. Please arrive at least 10 minutes early.
Payment is to be made at time of booking. American Express, Visa and Mastercard accepted.
Sorry, no refunds. Full credit can be applied to another class with at least 24-notice to cancel.
Phone Orders: (718)437-3558. Fax this form to: (718)437-6368.
Optimum Psychological Svcs, PLLC, 833 58th St, Ste 3R, Brooklyn, NY 11220