Bali Retreat Registration Form

Retreat Information

Name of Retreat:_______________________________________________________

Dates: from ________________to ____________________year_________________

Retreat cost- please specify package #__________: $_______________

Private room surcharge $_______________ ( only applies to package #2 and/or #3)

Total cost payable now: $_______________

Do you wish to pay in installments? _______________

 

Deposit/payment method:     Visa     Master Card Canadian email interac transfer

 

Card number___________________________________________Expiry date_____/_____

 PLEASE NOTE: Aziza Healing Adventures is a Canadian company. Unless you pay by US money order, the above fees are converted into equivalent Canadian dollars based on the exchange rate on the day fees are processed. Dollar rates fluctuate on a daily basis. If you are using an American or foreign dollar account, the conversion rate and final charge you are invoiced by your credit card company or bank may differ slightly from the rate shown above. Regrettably this difference is out of our control.

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 retreat start date. Your final payment is due 90 days prior to retreat starting date. Bookings made less than 90 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.                                      __________ (initial)

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)

I am aware that unless I'm otherwise notified of a retreat cancellation, this retreat will proceed, and that the registration cancellation policy is in effect and applies regardless of any political or weather related events taking place prior to the start or during the retreat dates.

 _________ (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                                            

 (initial) ______________

 

I have read carefully and understand this agreement.

I have read the Personal Insight Session description page found on the website www.aziza.ca.

I have read the specific website pages on www.aziza.ca describing this event, itinerary and fee package inclusions and exclusions. for which I'm registering and the registration policy webpage.

 

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

59 Crewe Avenue Toronto, Ontario, Canada M4C 2J2

e-mail info@aziza.ca