Registration Registration for Seeds of RenewalMay 4, 2024 9:00am – 1:00pm Levinson Hall, JCC Squirrel Hill 5738 Forbes Ave, Pittsburgh, PA Name(Required) First Last Email(Required) Enter Email Confirm Email Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number(Required)Age Range 16 – 34 years old 35 – 54 years old 55+ years old Your Pronouns(Required) How did you hear about this retreat? Tiferet email or newsletter JCC newsletter/advertising Retreat organizers (Sara, Julie, Edie) Friends/word of mouth Other Please list any serious food allergies or dietary requirements we should be aware of:The standard tuition covers this event’s basic costs, but we rely on your generosity to support our dedicated teachers. Please be as generous as you can to sustain this type of programming in Pittsburgh. Emergency Contact: Name(Required) Emergency Contact: Phone Number(Required) Consent(Required)Waiver: Disclaimer (Yoga injuries are rare, but we are required to ask you to sign the following release): I recognize that any form of physical activity is potentially hazardous with risk of possible injury or death. I hereby affirm that I am voluntarily participating in these activities and agree to expressly assume and accept any and all risks of injury and/or death. Likewise, I, my heirs, or legal representative of such forever release, waive, discharge, and covenant not to hold Tiferet Inc, and its representatives–Julie Newman, Edith Raphael, Edith Raphael Enterprises, LLC, and Sara Stock Mayo–responsible for any liability. I understand it is my responsibility to consult with a physician prior to and regarding my participation in this yoga class, retreat, or workshop. I also affirm myself to be physically sound and suffering from no condition, aliment, impairment, disease, or other illness that would prevent my participation in yoga activities. I have disclosed any and all ailments and/or medical history relevant to participation. These classes and related retreats/workshops involve breath focused ease and steadiness as well as self-acceptance—not over-striving and pain. I understand that it is ultimately my responsibility to modify a posture, or to assume a resting posture/asana like Child’s Pose if ever there is one I associate with pain or being beyond my ability. I affirm that I have read all of the above and accept:Retreat Tuition Standard $55.00 Benefactor $110.00 Supported $36.00 (or as you are able) Total Payment Method(Required) PayPal Credit Card Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.