Healthy Breast Course Materials Order Form | The Healthy Breast Program

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For Healthy Breast Educators, Yoga Instructors or Trainers teaching the Healthy Breast program as a yoga series or as the full program:

Due Date: Payment is due at least 1 week before the first classroom day of the program

Program # (sent to Licensee/Course Administrator when program was approved) - (mm/dd/yy to mm/dd/yy)

Program Dates (as submitted on contract) (mm/dd/yy to mm/dd/yy)

Actual program dates if different from contract (mm/dd/yy to mm/dd/yy)

Total number of students

Location (City, State/Province, Country)

Name of Course Administrator/Licensee

Name of Course Instructor or Lead Trainer (if different from above)

Name of person filling out this form

Your Email

Today's Date

Is your program a

Healthy Breast Yoga Program (yoga only, without background material) (1 ½ hour classes X 12)
Healthy Breast Foundations Program (1 ½ hour classes X 12)
Full Healthy Breast Program (yoga plus foundations). Must be at least 36 hours in length
Healthy Breast Foundations Certification Program (taught by a certified trainer)
Full Healthy Breast Certification Program (yoga plus foundations) (taught by a certified trainer)

Do you need copies of the

Healthy Breast Yoga Manual (yoga sets only, by module) ($10/person copyright fee)
Healthy Breast Foundations Manual ($10/person copyright fee)

How many copies to print

Calculated copyright fee

There is a $30 administrative fee to send the file to the copy shop.

Please provide the following information about a copy shop near you where the file can be sent with instructions to make a specific number of coil bound, double sided copies:

Copy shop name

Contact Person

Copy Shop Address

Copy Shop Email

Copy Shop Phone

Copy Shop Website

Please provide the following information for us to notify the copy shop of pickup and payment:

Name of person who will pick up copies:

Phone

I agree

I agree to pay the photocopying charges for my specified amount of Healthy Breast manuals (either yoga manual or full manual) to the copy shop named above at or before pickup.
I agree to respect copyright law by not photocopying the manual without permission, or allowing others to do so.

Name

Total Costs

# Manuals

# Manuals x Copyright fees

Administrative fee to send manual to copy shop

HST Tax (13%):

TOTAL

Please submit payment by etransfer to [email protected] and email this form along with it.

Please also submit your participant attendance sheet as an Excel doc (see template)