Registration Form Bhutan Yoga Retreat 2018 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 if booking is after June 20, 2017).*Early Bird (by 15th Feb, 2018) - Bhutan Yoga Retreat 2018, 7 days 6 nights US$2900Normal Rate (after 15th Feb 2018) - Bhutan Yoga Retreat 2016, 7 days 6 nights US$3300Please make your payment via funds transfer or telegraphic transfer. Your registration will be confirmed upon receiving payment. Please email firstname.lastname@example.org for transfer details. Cancellation & Refund Policy For early bird retreat rate, a non-refundable deposit (min. of S$200 of your total Fee) is required to secure a booking by 20th June 2017. The balance amount is due on 31st July 2017. For normal retreat fee, a non-refundable deposit of 30% is required to secure a booking. The balance amount is due 60 days prior to commencement of retreat. To reap the full benefits of the yoga that is practised at the Retreat, attendance at all meditations, yoga classes and 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 Chiang Mai 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. 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.CommentsThis field is for validation purposes and should be left unchanged.