Registration Form

Retreat Name _____________________________________

Departure Date ____________________________________

HOW DID YOU HEAR ABOUT US?

__ Word Of Mouth Who?_________________

__ Common Ground/Shared Vision magazine

__ Web site Which one? ___________________________

__ Search Engine? If yes, which one?                                                                           

__ Other (Please specify) ___________________________________________________

PARTICIPANT 1

Name (as it appears on your passport)

Mr. Mrs. Ms. ______________________________________                   

Street Address ___________________________________________       

City _______               ___                  ____ Province / State _________

Postal / Zip Code ______________ Country ______________

Email Address ______________________________________

Date of Birth _______________________________________

Phone (Day) _______________________________________

Phone (Evening _____________________________________

Nationality _________________________________________

SPECIAL DIET (please circle)

No   

Yes (Please describe below)

I require a special diet, or the following special services:

__________________________________________________________

__________________________________________________________

__________________________________________________________

TRAVEL INSURANCE

I understand that Trip Cancellation Insurance and Medical Insurance is highly recommended.

__ Yes, I plan to purchase trip insurance.

__ No, I DO NOT plan to purchase trip insurance.

Signed                                                              Date                           

ACCOMMODATION

I would like a

__ Shared Room    

__ Private Room

__ I am a single but would like to find a room mate. Please refer to single supplement section of the terms and conditions

 __ Camping. I am responsible for my own equipment

ADDITIONAL ACCOMMODATION (before and after Tour)

Please arrange accommodation for the following: 

City _____________________

Arriving _____________________

Departing ____________________

City ________________________

Arriving _____________________

Departing ____________________

AIR TRAVEL

Please make flight arrangements for me (us) 

__ YES  

From City _______________________________

Frequent Flyer No. ________________________

 __ NO 

 I will make my own flight arrangements to connect with this tour. 

PAYMENT OPTIONS

__ Payment in full  

__ Deposit of 50%

__ Cheque sent via regular mail

__ Please invoice me through Payapal with a 5% service fee

I have read and agree to the booking conditions and general information as outlined in the Terms & Conditions section. I also understand that the unique nature of this type of travel involves accommodations, transport, safety and medical facilities not found on a conventional vacation. By signing below, you are agreeing to those terms.

Address: ___________________________________________________

Date: _____________________________

Signature: _________________________