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Bali Retreat Registration
Form Retreat
Information Name
of Retreat:_______________________________________________________ Dates:
from ________________to ____________________year_________________ Retreat
cost- please specify package #__________: $_______________ Private
room surcharge $_______________ Total
cost payable now: $_______________
Deposit/payment
method: Visa Master Card Card number___________________________________________Expiry
date_____/___ Personal
Information Name:____________________________________________________________________
Address__________________________________________________________________ City:__________________State/Province________Postal/Zip_______________Country__ Phone#
Home__________________ Wk__________________ e-mail_________________ Cell
phone __________________________Your occupation___________________________ Related
Personal Growth experience, if any: _________________________________________________________________________ __________________________________________________________________________ ____________________________________________ Outdoor
activity skills: Hiking- Beginner
Intermediate advanced Swimming-
Beginner Intermediate advanced Age____________
Gender_____________ Height_____________ Previous
AHA Retreats ______________________________________________________ How
did you hear about us?___________________________________________________ Please
note any food allergies and considerations: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Emergency
Contact: Name_____________________________________________________ Relationship__________________address_______________________________________ Phone:
day____________________ evening __________________cell________________ Three
things that I am looking forward to on this retreat: 1.________________________________________________________________________ 2.________________________________________________________________________ 3.________________________________________________________________________ _________________________________________________________________________ I
have a travel partner I would like to share accommodations with: Yes_____
No______ Name__________________________________________e-mail_____________________
Booking and Cancellation Procedures All
Bali prices are in American dollars unless otherwise specified. Our
retreats are filled on first to pay basis. Your position is held with
a 50% deposit which becomes non-refundable, along with any other
payments, 120 days prior to Cancellations:
In the unfortunate instance that you must cancel your trip, we will
provide you with a full refund minus a $100.00 administration fee, unless
subject to the above time frames: In the unfortunate instance that the
minimum requirement of registrants is not secured, the retreat will
be canceled and all payments made to AHA towards the retreat fee will
be reimbursed to the registrant. The registrant is fully responsible
for any non refundable or non transferable transportation independently
booked and does so at his/her own risk. __________ (initial) Aziza
Healing Adventures exercises the right of discretion and with the sole
intention of ensuring a positive collective group experience can, at
anytime, decline applications from individuals who do not seem to be
suited to an AHA personal growth group retreat. Payment and cancellation
policy found on the web site overrides this agreement. Please review
the Registration web page policies. I
understand and accept AHA Retreat Booking and Cancellation conditions. Signature
______________________________________________________date____________ Medical Information Birth
date D/M/Y ____________________gender______ Height_______ Weight(optional)_________ Health
Insurance- Name & Number______________________________________________ Please
evaluate your health- emotional and physical: Fair_____ Good______ excellent______ Please
evaluate your fitness: Fair______ Good_____________ excellent_______________ List
any physical or medical limitations that might affect your participation
on this retreat: ________________________________________________________________________ ________________________________________________________________________________ List
any allergies that might affect you on this retreat:_______________________________ _________________________________________________________________________ _______________________________________________________________________________ Do you have any dietary restrictions? Yes________ No_______ If yes, please specify: ______________________________________________________________________________ __________________________________________________________________________ List any medication taken and for what condition: __________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________________________________ List
any major illnesses and the dates: ____________________________________________________________________________ ___________________________________________________________________________ ____________________________________________ Family
doctor: ____________________________________phone_______________________ I
have been to a physician in the last 12 months for a physical examination.
To my knowledge I am fit and emotionally capable of undertaking the
retreat outlined in the AHA web site information and itinerary pages. Signature___________________________________________________Date_____________ Waiver of All Claims, Release from Liability
And Assumption of Risks Agreement. To:
Aziza Healing Adventures (AHA) In
consideration of AHA accepting my application for participation in the
personal growth retreat from _____________to_____________,
year___________, I agree to this release of claims, waiver of liability
and assumption of risks. On behalf of myself, my heirs, executors, successors,
administers and assigns and any other person who may have an interest
at common law or by operation of statute, I hereby waive any and all
claims I or such parties may have now or in the future, and release
from liability AHA, its founder, directors, officers, employees, guides,
agents or representatives (" the releasees")
for any personal injury, death, property damage or loss or any nature
suffered by me as a result in participation in any activity on the retreat
with AHA due to any cause whatsoever including those arising out of,
or in any way connected to or occasioned by the negligence of the releasees. _________ (initial) I
am aware that personal growth activities are designed to promote emotional
awareness and I accept responsibility for my emotional health during
and after the retreat. I acknowledge the enjoyment and challenge I receive
from emotional risks involved in participating in personal growth activities
on personal growth retreats.
_________ (initial) _________ (initial) I
am aware that adventure travel, hiking, swimming and boating involves
risk, and in addition to the usual dangers and risks inherent in adventure
travel, hiking, swimming and boating there are certain additional risks,
some of which include: 1.
Terrain- Natural areas and waters are subject to natural forces which
result in obstacles and hazards. 2.
Isolation- Retreats are in wilderness and natural areas which may not
be regularly patrolled, and communication may be difficult and rescue
and medical treatment may not be available for hours or even days. 3.
Animals- Hiking, swimming, boating in natural areas may result in encounters
with wild animals and insects which may injure,
damage or capsize. 4.
Weather- Weather may change rapidly and may be extreme, presenting significant
challenges.
________ (initial) I acknowledge the enjoyment and challenge I receive
from hiking and the wilderness and natural outdoor experience, its isolation
and the opportunity to experience wildlife and nature in a natural surrounding
and state, and emotional experiences resulting from personal growth
exploration. This is my reason for participating in this retreat, and
I voluntarily assume all risks associated with these activities and
freely waive any and all legal rights that I may have against the releasees. I
am medically, physically, emotionally and in all respects fit and able
to participate in personal growth adventure travel. I have no medical
requirement or condition except what is outlined in the Registration/Medical
form. I
agree I will be fully and financially responsible for my own physical
condition and well being during the retreat and will follow the safety
precautions and instructions prescribed by AHA and its hired operators.
(initial) ______________ In
the unfortunate event that I choose to engage in legal matters with
Aziza Healing Adventures and/or its founder, directors, officers,
employees, guides, agents or representatives, I accept the terms that
all legalities will in totality be processed and proceed in
Toronto, Ontario, Canada I
have read carefully and understand this agreement. Dated_______________Signature of Participant _________________________________ Participant
printed name___________________________________________________ Signature
& printed name of witness _______________________________________________________________________ ________________________________________________________________________ If you are registering after Jan. 24, 2013 please call 705-652-9329 to speak to Louise Racine to arrange for fax forms and make payment. Thank you!
Aziza
Healing Adventures e-mail info@aziza.ca |