Registration Form Yamanashi Yoga Retreat 2019 Registration Form Name*FirstLastGender*FemaleMaleAge*Phone*Email*Address*Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryPlease put NA if an address field is not applicable. Please provide brief details of any medical conditions you have (allergies, injuries, heart conditions, etc). If none, please enter "none".*Are you pregnant?*YesNoN/AEmergency Contact Person *Emergency Contact Number*How long have you been practicing yoga?* Please select the retreat that you are booking for and the amount to be paid. (Normal Fee applies for bookings after 15th Mar, 2019).*Early Bird (by 15th Mar, 2019) - Yamanashi Yoga Retreat 2019, 5 days 4 nights S$2300Normal Rate (after 15th Mar 2019) - Yamanashi Yoga Retreat 2019, 5 days 4 nights S$2600Please make your payment via funds transfer or telegraphic transfer. Your registration will be confirmed upon receiving payment. Please email email@example.com for transfer details. Cancellation & Refund Policy For early bird retreat rate, a non-refundable 30% deposit of your total Fee is required to secure a booking by 15th Mar 2019. The balance amount is due on 15th June 2019. For normal retreat fee, a non-refundable deposit of 30% is required to secure a booking. The balance amount is due on 15th June 2019. To reap the full benefits of the yoga that is practised at the Retreat, attendance at all meditations, yoga classes and mindfulness workshops is mandatory, unless you are not feeling well. Please inform your instructors. I hereby agree that I have read the terms and conditions of this Yamanashi Japan Yoga Retreat organized by Carol Cheong Wai Mun and I agree to abide by these rules and to participate in all activities. I agree to take full responsibility for the decision to participate in all Retreat activities and mindfulness practices. In addition, I will not hold either Carol Cheong Wai Mun or Fernando Augusto Oliveira Vaquer de Pinho responsible for any injuries or damages that may result from the participation in Retreat activities. Have you read and understood the Retreat Terms & Conditions and do you agree to them?*YesNoThe Ompulence Retreat Registration Form can be submitted once all the fields are completed and you have read, understood, and agreed to the Retreat Terms & Conditions. Once the form is submitted, Ompulence Retreat will be in contact to complete the registration process with you. Thank you.PhoneThis field is for validation purposes and should be left unchanged.