Retreat Registration Form

Retreat Registration Form

Retreat Information

Name of Retreat:_______________________________________________________

Dates: from ________________to ____________________year_________________

Retreat cost: Package #_______________________________________ Cost $_______________

Private room surcharge if applicable $_______________ ( only if roommate is not available for shared packages)

HST 13% $ ______________ ( on Canadian Retreats only)

Total cost: $_______________

Deposit: $_______________

Balance due: $_______________/ DUE DATE ____________________

Deposit/payment method: money order Visa MasterCard

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

Age____________ Gender_____________ Height_____________

Previous AHA Retreats ______________________________________________________

How did you hear about us?___________________________________________________

Please note any food allergies, dislikes, 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.________________________________________________________________________

_________________________________________________________________________

FOR 5-DAY WOMEN'S RETREAT ONLY

Do you wish to reserve SPA sessions during the week. Sessions may include Massage, reflexology and other types of relaxing modalities.

Yes_________ No__________ Undecided__________ Spa fees vary with each session.

I have a travel partner I would like to share accommodations with: Yes_____ No______

Name__________________________________________e-mail_____________________

Booking and Cancellation Procedures

All prices are in Canadian dollars unless otherwise specified and do not include GST. 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, 45 days prior to Ontario weekend retreats, 60 days prior to Ontario 5-day retreats. Your final payment is due 60 days prior to retreat starting date. Bookings made less than 60 days before starting date require full payment. If a roommate for a solo registrant is not available, single supplement charges will be added to the double occupancy based retreat fee as outlined on the cost package page.

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_________

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)

I am aware that adventure travel, including hiking in a forested area involves risk, and in addition to the usual dangers and risks inherent in hiking in a forested area, there are certain additional risks, some of which include:

1. Terrain- Natural areas 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.

3. Animals- Hiking in natural areas may result in encounters with wild animals and insects which may injure.

4. Weather- Weather may change rapidly and may be extreme, presenting significant challenges.

________ (initial)

I acknowledge the enjoyment and challenge I receive from hiking in a 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.

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 fully accept the terms that all legalities will in totality be processed and proceed in Toronto, Ontario, Canada

(initial) ______________

I have read carefully and understand this agreement.

I have read the Personal Growth Session description page found on the web site.

I have read the specific web site pages describing this event for which I'm registering.

Dated_______________Signature of Participant _________________________________

Participant printed name___________________________________________________

Signature & printed name of witness _____________________________________________________

___________________________________________________________________________________

Please mail or fax to: Aziza Healing Adventures 416- 696- 0087

59 Crewe Avenue Toronto, Ontario, Canada M4C 2J2

phone 416-696-0086, fax 416-696-0087, e-mail info@aziza.ca