BLISSFUL BALI WELLNESS YOGA RETREAT
14th – 20th OCTOBER 2018 - REGISTRATION FORM
Name:Address:
Email :
Tel: (H) / (M) / (W)
DOB: / Occupation:
Contact person (in case of emergency)
Name / Phone:
Yoga/Medical History
Previous yoga experience (if any):
Please describe your general physical health:
Please indicate (with an x) if you suffer from, or have ever been treated for any of the following:
Arthritis / Cancer / Knee problems/surgery
Asthma / Clinical depression / Low blood pressure
Back problems / Neck problems / High blood pressure
Eye conditions / Migraine / Heart conditions
Please provide more details if necessary, or of any other relevant medical conditions:
Are you pregnant? Yes / No / If yes, how many weeks
Are you taking any medication that I should know about: Yes / No
If yes, please provide details:
What are the main reasons you are interested in attending this retreat?
Please advise any special dietary requirements ______
Accommodation Preference / Please note single rooms are limited and will be allocated to the first bookings. If sharing please specify who with otherwise we will endeavour to allocate you a same sex room buddy (dependent on bookings).
EARLY BIRD
Book by 30 Jun 2018 Single Room $2,080 / OR Share Room $1,770
REGULAR RATE
Book from 1 July 2018 Single Room$2,180 / OR Share Room $1,870
I enclose my (non-refundable) deposit of $300 □
If paying by electronic funds transfer (EFT) or in person at any National Australia Bank–
Acc Name: Julia Jones BSB 083 376 Acc No 462085993
I accept full responsibility for my health, well-being and personal belongings while attending the yoga retreat.
Signature: / Date:You will require a current passport to travel with at least 6 months validity remaining.
I highly recommend you take out travel insurance for your trip to cover any type of contingencies such as flight cancellations etc. If unforeseen circumstances occur and you need to cancel your booking please be aware that certain costs such as accommodation may not be refundable.