Bali Private Workshop Registration Form

Length of Workshop:_______________________________________________________

Dates: from ________________to ____________________year_________________

Total cost: $_______________

Deposit/payment method:   cash     Visa        MasterCard information to be given over the phone

 

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:

_______________________________________________________________________________

________________________________________________________________________________

____________________________________________________________

Age____________ Gender_____________ Height_____________

Previous AHA Retreats ______________________________________________________

How did you hear about us?___________________________________________________

Please note any food allergies or special considerations for snacks provided: _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Emergency Contact: Name___________________________________________________

 

Relationship__________________address_______________________________________

Phone: day____________________ evening __________________cell________________

 

Three things that I am looking forward to in this workshop:

1.________________________________________________________________________

2.________________________________________________________________________

3.________________________________________________________________________

_________________________________________________________________________

 

Booking and Cancellation Procedures

All prices are in Canadian dollars unless otherwise specified. Scheduling is filled on first to pay basis.

Payment is due in full at time of registration. Please email to be provided with the phone number

to call in your credit card informaion. Please note accommodations, transportation and meals

are not included in fees.__________ (initial)

 

Cancellations: In the unfortunate instance that you must cancel your session,

we will provide you with a full refund minus a $100.00 administration fee,

if written notice is given more than 22 days in advance.

Cancelations made 21 days or fewer before scheduled session are non refundable.

__________ (initial)

Aziza Healing Adventures and its owner and officers are not responsible for transportation,

accommodation or meal satisfaction, safety and availabilty. Each registrant is completely

responsible for all contracts and fees applicable to their choice of transportation, accommodation and meals.

__________ (initial)

 

I understand and accept AHA Retreat Booking and Cancellation conditions.

 

Signature ______________________________________________________date____________

 

Medical Information

 

Birth date D/M/Y ____________________gender______ Height_______

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 in this session:

__________________________________________________________________________

______________________________________________________________________________

List any allergies that might affect you in this session:_______________________________

___________________________________________________________________________

_____________________________________________________________________________

In case of emergency list Any medication taken and for what condition: ____________________________________________________________________________________________

_____________________________________________________________________________________________

_______________________________________________________________________________________

In case of emergency 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 session outlined in the AHA web site information 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 session 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 workshop sessions. I acknowledge the enjoyment and challenge I receive from emotional risks involved in participating in personal growth activities on personal growth workshops.                                                                         _________ (initial)

 

I am aware that tropical locations like Bali, Indonesia involve risk, and in addition to the usual dangers and risks inherent in Bali, 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- Workshops are in isolated 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- Walking and swimming in Bali may result in encounters with wild animals and insects which may injure or damage.

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

                                                                                                                         ________ (initial)

 

 I acknowledge the enjoyment and challenge I receive from participating in my personal growth in Bali, 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 workshop, 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 workshop 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.

 

Dated_______________Signature of Participant _________________________________

 

Participant printed name___________________________________________________

 

Signature & printed name of witness _______________________________________________________________________

 

________________________________________________________________________

 

Please email form as completed document to: info@aziza.ca

 

 

 Aziza Healing Adventures

59 Crewe Avenue Toronto, Ontario, Canada M4C 2J2

phone 1-416-696-0086,    fax 1-416-696-0087           e-mail info@aziza.ca