Please tell us why you are excited to come on this trip:
Are you currently on any medications and/or seeing a doctor for any reason? If so, Please explain.
Will you be paying with cash_____ credit_____check_____
____ $2800 *Earybird price! Register by August 1st, 2014
____ $3200 Standard price
Please send or deliver a $1000 deposit to hold your place
The remaining balance will be due by September 19th, 2014. Check’s Made Payable to:
Bud Tansey Credit Card Information: *Please note that there will be a 4% capture fee for CC payments.
Type of Card:_________________ Card Number:______________________________________
Expiration Date: MM____/YY____ Cvc(Security code on the back):_______________________
Billing Address & Zip Code:________________________________________________________
Bud & Dhyana
Please call or write Dhyana with any questions.
(352) 328-8152 - Dejavu.firstname.lastname@example.org
Liability Waiver Form for Journey to Sacred India To the best of my knowledge, I am in good physical condition and fully able to participate in the Journey to Sacred India. I am fully aware of the risks and hazards connected with the participation in this trip, including physical injury or even death, and hereby elect to voluntarily participate in said trip, knowing that the associated physical activity may be hazardous to me and to my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or loss or damage to property owned by me, as a result of participation in this trip.
I hereby RELEASE, WAIVE, DISCHARGE, AND COVENEANT NOT TO SUE Dhyana Masla and Brad Tansey from any and all liability, claims, demands, action and causes of actions whatsoever arising of or related to any loss, damage or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in physical activity, or while on or upon the premises where the event is being conducted.
It is my expressed intent that this release and hold harmless agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVE, DISCHARGE, and CONVENTION TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of New York.
In signing this release, I acknowledge and represent that I HAVE READ THE FORGOING Waiver of Liability and Hold Harmless Agreement, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreements have been made and I EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND COMPLETE CONSIDERATION FULLY INTENTING TO BE BOUND BY SAME.
Signature ____________________________ Date _____________
Print name ____________________ _______Date _____________
Name of the trip you are attending: _________________________
Guardian if under 18:_____________________________________