Taijiquan style Chen des Laurentides 陈氏太极拳

Taijiquan style Chen des Laurentides
陈氏太极拳 REGISTRATION FORM
Office use
Registered on :
Billed on :
TAI CHI RETREAT IN COSTA RICA
Payment received :
Place reserved :
Please fill the form below. You cannot save your data on your computer. Print it, sign it and return it to me by email or regular mail. PERSONAL INFORMATIONS
First name Last name Address City Country Province/State/Department Home phone number Email address Cell phone number Date of birth (dd-mm‐yyyy) :
Language spoken French : English : Person to reach in case of an emergency : Postal Code Passport number :
Their phone number : Other : ______________________ Their email address : If yes, please specify: Do you have any food allergies, intolerances or restrictions? YES NO
RESERVATIONS/REGISTRATION (PRICE PER PERSON)
$1430 US Single occupancy Double occupancy $1130 US $1030 US Triple occupancy $930 US Dorm (4 ‐ 6 persons) Name of the person who will share the room with you : Names of the 2 persons who will share the room with you :
Please indicate, if applicable, the name(s) of the person(s) you want to share the dorm with : Karine Van Chesteing, Certified Chen style Taijiquan Instructor
140 chemin Fournel, Ste-Anne-des-Lacs, Québec, J0R 1B0
Tel. : 450-643-0132
Email : karine.vanchesteing@gmail.com DETAILS OF YOUR JOURNEY
Will you use the shuttle included in the retreat? On arrival? YES NO Date of arrival : Time of arrival : Airline : Flight number : At departure? YES NO Departure city : Date at departure : Time of departure : Airline : Flight number : Destination city : PAYMENT DETAILS
Registration price according to occupancy : Early bird special if registered and paid by July 4th, 2015 : DUE AMOUNT : 1,130 $
US
- 100 $ US (if applicable)
US
WAIVER OF LIABILITY
This agreement releases Taijiquan style Chen des Laurentides from all liability relating to injuries or
illnesses that may occur while attending or participating at this Tai Chi retreat in Costa Rica. By signing this
Registration form, I ______________________________ (full name of participant), living at
__________________________________________________ (address), I agree to hold Taijiquan style
Chen des Laurentides, Karine Van Chesteing, The Goddess Garden Eco Resort & Spa, or any organizations
related to the event, sponsors, advertisers, owners or landlord where the event is taking place or other
retreat participants entirely free from any liability, including financial responsibility for injuries incurred,
regardless of whether injuries are caused by negligence.
I hereby acknowledge that my participation to this Tai Chi retreat presents risks of personal injury and
assume all responsibility for any and all damages, injuries or losses that I may incur while attending or
participating at this Tai Chi retreat. I declare that I am in good health and physical condition suitable to
take part in this retreat, with no medical condition, physical impairment or psychological condition that
may be aggravated by engaging in such activity.
I give the organizer permission to use my name and my photograph for written or broadcasted advertising
on television, radio, and social media or for their own internal use.
SIGNATURE: ______________________________________DATE:___________________________
Karine Van Chesteing, Certified Chen Style Taijiquan Instructor
140 chemin Fournel, Ste-Anne-des-Lacs, Québec, J0R 1B0
Tel. : 450-643-0132
Email : karine.vanchesteing@gmail.com