2020 Bali Retreat Registration Form
"Breath of Perspective" Nature, Culture & Yoga Adventure with Root 2 Rise Yoga on June 26-July 2 or 5
Email address *
First & Last Name: *
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Phone Number & Any Alternate Phone Number(s): *
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City, State & Country of Residence: *
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Please tell us your intention for joining this retreat, including anything you hope to experience: *
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How did you learn about this retreat? *
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Today's Date: *
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Choose your length of stay (Check-in is after 2pm. Check-out is by 12pm): *
Choose your accommodation type. *
**If you selected "Shared" for your accommodation type, please name your roommate and indicate if you request separate beds, and we will accommodate your request based on availability.
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Fitness Level/Health Needs -- Bali has a tropical, warm (80F) and humid climate year round, and June/July are during "dry season." This is a moderately physically active retreat. We'll walk through villages with uneven ground and hike in nature with potential inclines and river crossings over rocks. If you may need specific physical, health or other accommodations, please explain below. (Please discuss this with your retreat host prior to registering to ensure this retreat is appropriate for you.) *
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List 2 emergency contacts with their names, phone numbers, emails and state/country of residence: *
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Meal Preferences or Dietary Restrictions: *
Please indicate any types of foods you do not eat (indicating any allergies) or type of diet you adhere to, whether it's all the time or only for some of your meals. This will be essential in choosing the meals you will be provided.
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T-shirt Size (for your souvenir gift): *
What is your length and type of experience with yoga and meditation, if any? *
All levels and styles of yoga experience are welcome.
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Please read our Cancellation Policy and type your name as your signature of agreement below. Root 2 Rise Yoga, Michelle Chua and their affiliates in Bali, Indonesia will do their best to facilitate an enjoyable inspiring nature, culture and yoga adventure retreat abroad. In rare unforeseen circumstances, plans may change. The following outlines Root 2 Rise Yoga’s cancellation policy: 1.) Should you, the retreat participant, choose to cancel your participation in this retreat, you must state it in writing via email to Root2RiseYoga@gmail.com. 2.) The first $500 of your payment, per participant, is non-refundable and non-transferable. 3.) Cancellations before January 1, 2020 will be refunded total payment minus $500 USD deposit. Cancellations after January 1, 2020 will not be refunded or credited. 4.) Your total balance for the retreat must be successfully received by March 15, 2020 to secure your reservation. Otherwise, your space will be forfeited without a refund or credit. 5.) You are advised to purchase traveller's insurance on your own when purchasing your flight, in the case of unsafe conditions for international travel to Bali or unforeseen cancellations. Michelle Chua and Root 2 Rise Yoga are not responsible for your expenses incurred in preparation for any canceled retreat. These may include airline tickets, loss of work, or other costs associated with preparing for your trip. 6.) Please read carefully on the retreat webpage what is included and not included in this retreat, as your registration verifies your agreement of these conditions. ***Please type your full name below as your electronic signature of agreement to our Cancellation Policy. *
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Please read our Liability Waiver and type your full name below as your signature of agreement to these terms: While Root 2 Rise Yoga and Michelle Chua prioritize your safety above all, there are inherent risks involved in traveling and participating in physical activities, such as yoga, outdoor adventure and recreation. These risks are not limited to damage or loss of personal belongings and personal injury. By signing below, you, the retreat participant, state that you are in satisfactory health and suffer no physical impairment to voluntarily participate in the yoga sessions, outdoor adventure and recreation per retreat description. You accept and assume all risks existing in those activities and in traveling within Bali, Indonesia. You agree to research the risks of those activities and of travel for which you are not aware. You agree to inform Michelle Chua and Root 2 Rise Yoga prior to registering for this retreat of any allergies, dietary needs or preconditions that may affect your and others’ safety and well being. You are responsible for bringing sufficient medications or health aids you may need in a manner that is legally approved for international travel and within Indonesia. You and your associates (i.e., family, friends, etc.) voluntarily waive any claim to maintain a lawsuit or demands of any kind against Root 2 Rise Yoga, Michelle Chua, their staff and their affiliates in Bali, including where you will be hosted, for any injury, illness, death, accident or loss or damage of personal property, which may occur during your participation on a nature, culture and yoga adventure retreat abroad. We recommend that all participants purchase travel insurance that covers emergency medical care, cancellation of flights and for loss or theft of personal items. *
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Please indicate the payment amount and means of payment that you will submit to secure your registration. Payments in US Dollars are accepted via cash, cashier's check, PayPal or credit card, the latter two accruing a 3.5% service charge. Checks can be made payable to "Root 2 Rise Yoga" and mailed to: 3940 Laurel Canyon Blvd. #313 Studio City, CA 91604. Please submit payment only after this registration form has been accepted and space availability is confirmed. *
$500 is your non-refundable, non-transferable deposit. *By March 15, 2020, full payment amount is required to hold your space on this retreat. Failure to pay balance on time will forfeit your spot.
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Thank you for your interest in joining us in Bali, Indonesia!
A copy of your responses will be emailed to the address you provided.
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