Aziza Healing Adventures
PATTERN BUSTING Workshops
Registration Form

Workshop Name: ________________________________________________
Workshop Date: ____________________________

Personal Information: Name:___________________________________________________________
Address__________________________________________________________
________________________________________________________________________________________________________________________________
City:____________________________State/Province_______________
Postal/Zip_____________________ Phone# Home______________________ Wk or cell______________________e-mail_________________________
Your occupation_______________________________Age______ Gender ____

Bringing a friend? Ask about your discount info@aziza.ca

Name of friend _______________________________________

e-mail of friend____________________________________________________

Cost: $____________________ PROMOTION CODE _______________________ (if applicable)
HST 13% ______________
This Fee is NON REFUNDABLE
Deposit/payment method: Visa/ MasterCard/cash/ email interac transfer ( in Canada only)
Card number_____________________________________________________
Expiry date______/_____

Related Personal Growth experience, if any ____________________________________:____________________________
Previous AHA Workshops or Retreats__________________________________ How did you hear about us?__________________________________________

What you are looking forward to on this Workshop: ________________________________________________________________
________________________________________________________________

Emergency Contact:Name____________________________ Relationship______________________ cell #:_________________________

Booking and Cancellation Procedures:
Full payment is due upon registration. Please fill out this form and send to contact info below.
All fees are NON REFUNDABLE.


I am aware that personal growth activities are designed to promote my emotional awareness and I accept full responsibility for my emotional health during and after the workshop. I acknowledge the enjoyment and challenge I receive from emotional risks involved in participating in personal growth workshops and activities. 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 workshop.

I understand and accept AHA Retreat Booking and Cancellation conditions.

Signature ____________________________________________________________
Date_________________________________________________________

Please mail or fax your application to: 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


THANK YOU!!!