Bali Retreat Registration Form
Name of Retreat:_______________________________________________________
Dates: from ________________to ____________________year_________________
Retreat cost- please specify package #__________: $_______________
room surcharge $_______________
( only applies to package #2 and/or #3)
( only applies to package #2 and/or #3)
Total cost payable now: $_______________
you wish to pay in installments? _______________
Do you wish to pay in installments? _______________
method: Visa Master Card Canadian email interac
Canadian email interac transfer
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.
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.
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_____________________________________________________
Phone: day____________________ evening __________________cell________________
Three things that I am looking forward to on this retreat:
I have a travel partner I would like to share accommodations with: Yes_____ No______
Booking and Cancellation Procedures
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.
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.
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)
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.
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.
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.
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.
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.
have read the Personal Insight Session description page found on the
I have read the Personal Insight Session description page found on the website www.aziza.ca.
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.
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