Bali Private Workshop Registration Form
Length of Workshop:_______________________________________________________
Dates: from ________________to ____________________year_________________
Total cost: $_______________
method: cash Visa MasterCard information to
be given over the phone
information to be given over the phone
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___________________________________________________
Phone: day____________________ evening __________________cell________________
Three things that I am looking forward to in this workshop:
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
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
to call in your credit card informaion. Please note accommodations, transportation and meals
are not included in fees.
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.
Healing Adventures and its owner and officers are not responsible for transportation,
Aziza Healing Adventures and its owner and officers are not responsible for transportation,
or meal satisfaction, safety and availabilty. Each registrant is completely
accommodation or meal satisfaction, safety and availabilty. Each registrant is completely
for all contracts and fees applicable to their choice of
responsible for all contracts and fees applicable to their choice oftransportation, accommodation and meals.
I understand and accept AHA Retreat Booking and Cancellation conditions.
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.
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.
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.
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
I have read carefully and understand this agreement.
Dated_______________Signature of Participant _________________________________
Participant printed name___________________________________________________
Signature & printed name of witness _______________________________________________________________________
email form as completed document to: firstname.lastname@example.org
phone 1-416-696-0086, fax 1-416-696-0087 e-mail email@example.com