HEAVEN ON EARTH BALI RETREAT 2018

Registration Form

 

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Call us at 1-416-696-0086

Name of Retreat: HEAVEN ON EARTH BALI RETREAT 2018


Dates: from __February 19____to ___February 22___year__2018___

 

Personal Information

 

Name:__________________________________________________________________________________

 

Address_________________________________________________________________________________

 

City:__________________State/Province________Postal/Zip_______________Country__________________

 

Phone# Home__________________ Wk__________________ e-mail_______________________________

 

Cell phone __________________________Your occupation_________________________________________

 

 

RETREAT WORKSHOP FEE
(SEPARATE FROM RESORT COST)

 

FEE INCLUDES:
15 min. interview, 4 workshops, materials, workbook plus any additions as noted below per package

 

PLEASE CHECK YOUR CHOICE

 

_____ INDIVIDUAL package rate

 

_____ GROUP OF _______ package rate. Please name members of your group. _______________

______________________________________________________________________________

______________________________________________________________________________

 

 

 

PLEASE CHECK YOUR CHOICE & FILL IN CURRENT WEBSITE WORKSHOP FEE

 


#1
____$__________ I AM SO ALL IN PACKAGE includes Heaven on Earth Workshop PLUS:

  • Private 1 hour Session with Laila Ghattas
  • Laila Goddess "Most Comfortable Pants on the Planet" in Black
  • Private 2 hours post retreat follow up Sessions with Laila

 

#2 ____$__________ I AM SO WORTH IT PACKAGE includes Heaven on Earth Workshop PLUS:

  • Private 1 hour Session with Laila Ghattas
  • Laila Goddess "Most Comfortable Pants on the Planet" in Black

 

#3 ____$__________ I AM SO FABULOUS PACKAGE includes Heaven on Earth Workshop

 

~~~~~~~~~~~~~~~~~~~~~

 

FEES are in the currency of your resident country.
CURRENCY OF YOUR RESIDENCE IS: _______________


PACKAGE PAYMENT METHOD: Fees listed on the website are discounted and reflect these payment methods: Canadian email interac etransfer / Wire Transfer / Money Order

Bank details to be discussed on the 15 min. interview.


Please call to discuss if you need to arrange another payment method with unpublished regular workshop fees.

 


ABOUT YOU


Related Personal Growth experience, if any:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Age____________ Gender_____________


How did you hear about us?_____________________________________________________________

 

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______

My travel companion will also be participating on the retreat: Yes_____ No______

 

Name__________________________________________e-mail____________________________________

 

 

Booking and Cancellation Procedures

 

 

Our retreats are filled on first to pay basis.
Your position is held with your NON REFUNDABLE WORKSHOP FEE.


Please reserve your room and make note of any food considerations with the travel agent found on the web page www.aziza.ca/bali.htm


I understand it is my responsibility to be informed of resort cancellation policy.

________ (initial)

CANCELLATIONS

If the 2018 Bali Retreat is cancelled by Aziza Healing Adventures you will receive a FULL REFUND for workshop fees. (Less cost for pants if included in your package and already worn)

In the unfortunate instance that you cancel your registration, please do so in writing. Your retreat fee for FOUR group workshops in Bali will be credited towards 7 hours private self-discovery sessions by phone or skype with Laila Ghattas. Please complete these sessions within six months of your written cancellation notice. If you have chosen package #1 or #2 that include private sessions, this credit will be in addition to those package hours.

 

Retreat Workshop Fees are NON REFUNDABLE without exception__________ (initial)

 

Please note your are solely responsible for all non refundable and non transferable travel arrangements and do so at your own risk.                              __________ (initial)


I have discussed any concerns with the above cancellation policy and retreat questions during the 15 min. pre registration interview. ________ (initial)

 

I understand and accept Aziza Healing Adventures Retreat Booking and Cancellation conditions.

 

Signature ______________________________________________________date____________

 

 

Medical Information


Travel Health Insurance- Company Name & policy Number _____________________________________________________________________________________

Travel Health Insurance Company contact number_____________________________________________ This information can be provided when purchased. Please pack a copy of your medical travel insurance policy.

 

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:_______________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Have you informed the resort of any dietary restrictions? Yes________ No_______

_________ (initial)

To my knowledge I am fit and emotionally capable of undertaking the retreat outlined in the AHA web site information.

 

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 or other unforeseen events taking place prior to the start or during the retreat dates.

 _________ (initial)

 

I am aware that Aziza Healing Adventures and its operator is not responsible for the quality of service, meals, spa treatments, amenities, classes, yoga, tours, activities, transfers and room, and anything else supplied or arranged by the travel agent and resort. _________ (initial)

 

I understand Aziza Healing Adventures and its operator is responsible only for facilitating the Heaven on Earth Bali Retreat workshops as outlined on the web pages. I understand it is for this workshop facilitation I am paying the above fees.

_________ (initial)

 I am aware that adventure travel, driving, swimming and boating involves risk, and in addition to the usual dangers and risks inherent in adventure travel, driving, 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 remote and natural areas, and rescue and medical treatment may not be available for several hours.

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 natural outdoor experience, its isolation and the opportunity to experience 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.

(initial) ______________


I have read the specific web site pages on
www.aziza.ca/bali.htm describing this event, itinerary and fee package inclusions and exclusions for which I'm registering.

(initial) ______________

 

 

 

Dated____________________________


Signature
of Participant __________________________________________________________________

 

Participant printed name__________________________________________________________________

 

Please save file, fill it out, save, then attach in an email to happy@lailaghattas.com

 

Aziza Healing Adventures

59 Crewe Avenue Toronto, Ontario, Canada M4C 2J2

e-mail: happy@lailaghattas.com , Phone: 1.416 .696.0086