BALI: YOGA + ADVENTURE RETREAT 2024
with Jessica Chin

Sunday, February 18, 2024 – Sunday, February 25, 2024
Ubud, Bali • 8 days | 7 nights

REGISTRATION FORM

I am thrilled to have you join me on this epic adventure! It will be an adventure of a lifetime! Our beautiful villa is BeingSattvaa.

To complete registration:

Please fill out the form below and
Provide your mobile payment service (i.e. Venmo, Zelle, Paypal, and your handle). Jessica will send a payment request for the $800 initial deposit.

Thank you! Once you register, more details will be shared! I look forward to sharing this incredible experience with you!

Name

First Name

Last Name

Phone Number

(###)

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Mobile Payment Type

Mobile Payment Handle

(name, number, email, etc.)

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

Emergency Contact Number

(###)

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ROOM SELECTION

Select Your Room Choice: (All rooms have private ensuite bathrooms.)

PLEASE FILL OUT THE FOLLOWING SO I CAN GET TO KNOW YOU BETTER!

How long have you practice yoga? How often do you practice yoga? Who/where do you practice yoga with?

What comes easiest to you in your yoga practice? What has been the most challenging in your yoga practice? What is something you want to explore more of in your practice?

Are you interested in meditation and breathwork practice?

Do you have any injuries? Or medical conditions that we need to be aware of? If so, what are they?

Do you have any food allergies? Or dietary restrictions? If so, what are they?

What is something you hope to do in Bali? (i.e. sights, expectations, etc.)

Any other comments/messages?

Non-Refundable + Non-Transferable Deposit

Yes, I understand a $800 deposit is required to secure my spot on this retreat and is non-refundable and non-transferable. All final payments must pay in full by December 18, 2023.

ASSUMPTION OF RISK, HEALTH WARRANTY, RELEASE & WAIVER OF LIABILITY:

Yes: I understand and accept the terms below.

Yoga is an individual experience and I understand that I should progress at my own pace while participating in the physically active portions of "Bali: Yoga + Adventure Retreat 2024" with Jessica Chin ("JC"). If at any point I feel overexertion or fatigue, I will respect my own body’s limitations and I will rest before continuing Yoga or any other exercise. I acknowledge that participation in "Bali: Yoga + Adventure Retreat 2024" naturally involves the risk of injury to me. I further acknowledge that specific risks include injuries resulting from overexertion, physical adjustment, improper or negligent use of equipment, failure to follow teacher instructions, or injuries resulting from participation in an inappropriate level of physical exercise. As such, I understand and voluntarily accept these risks. I represent that I am in good health, at least 18 years of age, have the necessary current medical approval to engage in physical exercise and yoga instructional classes and have no disability, impairment, injury, disease or ailment which would cause risk of injury or adverse health consequences as a result of engaging in physical exercise and yoga instructional classes. I acknowledge that to the facility where I am participating in my retreat and Jessica Chin are relying on this representation and I understand that neither to the facility where I am having my retreat nor JC will investigate or certify my health or my fitness to participate in physical exercise and yoga instructional classes.

RELEASE AND WAIVER OF LIABILITY:

Yes: I understand and accept the terms below.

In consideration for my participation in "Bali: Yoga + Adventure Retreat 2024" with Jessica Chin, I, individually, and on behalf of my relatives, legal representatives, and assigns, agree not to sue and hereby agree to defend, indemnify, release and hold harmless to the facility where I am doing my retreat and Jessica Chin ("JC") and each of their respective shareholders, owners, officers, directors, members, employees, contractors and agents, and the owner of the Beingsattvaa (the “Facilities”) where the Retreat occurs (collectively, the “Releasees”) from all actions, claims, demands, suits, losses, liabilities, charges, expenses (including, without limitation, attorneys’ fees), and costs of any nature whatsoever which may arise out of, relate to, or result from, any injury, economic loss or any damage to me or my guest or relatives resulting from my participation in physical exercise and yoga instructional classes at the Facilities, entry to or use of the equipment, facilities or services at the Facilities, the negligence of to the facility where I am doing my retreat or Jessica Chin, anyone at to the facility where I am doing my retreat or Jessica Chin’s behalf or anyone using the Facilities or JC’s equipment, facilities or services, except such as may arise out of the gross negligence or willful misconduct of the Releasees. This release and waiver of liability (this “Release”) is intended to be a complete release of any responsibility for personal injuries and/or property loss/damage sustained by me while at the Facilities, whether using exercise equipment, participating in active or passive exercise, or not. I understand that this Release is intended to be as broad and inclusive as it permitted by the laws and jurisdiction applicable to the facility where I am taking my training and that if any portion of this Release is held invalid, I agree that the balance of this Release should continue in full force and effect.

PLEASE TYPE YOUR FIRST & LAST NAME BELOW.

(This serves as an electronic signature.)

BALI: YOGA + ADVENTURE RETREAT 2024 with Jessica Chin

Sunday, February 18, 2024 – Sunday, February 25, 2024 Ubud, Bali • 8 days | 7 nights