First Name:    *

 

Last Name:    *

 

Sex:               * FEMALE MALE

 

Date of Birth:    *

(eg. 23/04/73)

Nationality:    *

 

Passport Number:    *

 

Expiry Date:  (eg. 23/04/73)  *

 

Age Group:   

(please select)       18 to 25 26 to 32 33 to 40 41 to 52 52 to 65 66+

 

English Speaker:   YES NO

 

Address:   

Town/City:     *

Zip/Postcode:  

Country:        *

Tel:                 

E-mail:           *

I wish payment in the following ways*

 

Pay the full amount by PAYPAL immediately of GBP £699.00, or

Pay over 4 stages by PAYPAL:

1) Receive INITIAL DEPOSIT of just GBP £99.00 immediately upon booking. 

2) Receive SECOND Payment of £200.00 by: 30/06/13,

3) Receive THIRD Payment of £200.00 by: 31/07/13, and

4) Receive FINAL payment of £200.00 by 31/08/13.

 

Restrictions/Requirements:

Special Needs: Dietary/Physical/Phobias etc (Some food preferences and sensitivities can be catered for) - please provide further details here:*    

 

 

 

During trip, I would like to share a hotel room with another participant:               YES NO

 

     Name of other participant:  

 

     Type of Room Required:                   Select Double Twin

 

 

 

I will arrange my own flights and travel insurance and I will confirm these details to the Trip Organisers:                YES NO

 

 

Confirmation of Your Participation:

I have read and understood the Terms and Conditions for the Event and I fully acknowledge that this is a Group Event whereby we each endeavour to participate in the planned healing activities as fully as possible and agree that I am responsible for improving my own sense of wellbeing and happiness. (please select YES/NO)

 

  YES NO

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