Inner Journeys Booking Form

Please print this form and return it, enclosing payment, to Inner Journeys (NSW) Pty Ltd,
P O Box 433, Ettalong Beach NSW 2257, Australia.
Fax: (Intl.+61) 02 9475 4034

Deposit

A non-refundable deposit of Australian Dollars AUD$500.00 per person, per program is required when booking. For bookings less than 8 weeks prior to departure full payment is required at time of booking.

Balance of Payment

The balance of payment for all programs is required to be received by Inner Journeys 8 weeks prior to program operation.

Please note that your signature may be required twice under
(a) booking declaration (b) credit card payment.

Program Code _________________________ Dates _______________

PARTICIPANT 1

Where more than one person is travelling together all communications will be directed to participant one unless otherwise requested.

First Name _______________Middle initial___Family Name_________________________

Mail Address_______________________________________________________________

Suburb________________________ State/Province_______________ Post Code________

Country__________________________ Date of Birth DD/MM/YYYY ___________________

Ph (Day)_________________________ Ph (Eve)___________________________

Mobile Ph ___________________________ Fax ___________________________

Email _____________________________________________________________

Vegetarian (Yes/No) ____ Any special diet requirements _____________________________

_________________________________________________________________________

Nationality as on Passport______________________________

Passport Number _________________________________________

Passport Expiry Date ______________________________________

Please note that it is your responsibility to ensure that you have a current passport with a validity date a minimum of 6 months after the completion of travel. It is also your responsibility to obtain any visas or vaccinations that you may require. If you are applying for a passport please register for the program and advise Inner Journeys of your new passport details prior to travel.

Room Type Preferred

Circle preference.

Single

Twin/Queen bedded

Share with ____________________________________

Health

As some of the programs are conducted in remote locations and/or may feature workshops which highlight emotions, please indicate whether you have suffered any major emotional illness in the last five years or are under any medical or psychiatric supervision.

If you answer yes to any of these questions please specify below. Circle one. YES / NO

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

If appropriate, please also confirm in writing that you are fit to travel and enclose a doctor's certificate of fitness to travel.

In case of emergency, whilst attending the program, please include the name of a contact person.

Name______________________________________________

Relationship to Participant ______________________________

Ph (Day)_____________________________________

Ph (Eve)_____________________________________

Acceptance of Booking Conditions (All participants to sign)

I have read and confirm my acceptance of Inner Journey's Booking Conditions as detailed in the Inner Journey's Web Site.

Name_______________________________ Signature ____________________________

Date ___/____/_______

PARTICIPANT 2

Where more than one person is travelling together all communications will be directed to participant one unless otherwise requested.

First Name _________________Middle initial___Family Name________________________

Sex (M/F)___ Date

Mail Address_________________________________________________________________

Suburb__________________________ State/Province_______________Post Code______

Country_________________________ Date of Birth DD/MM/YYYY ___________________

Mobile Ph ____________________________________ Fax _________________________

Vegetarian (Yes/No) ____

Any special diet requirements _________________________________________________

_____________________________________________________________________________

Nationality as on Passport___________________________________

Passport Number __________________________________________

Passport Expiry Date _______________________________________

Please note that it is your responsibility to ensure that you have a current passport with a validity date a minimum of 6 months after the completion of travel. It is also your responsibility to obtain any visas or vaccinations that you may require. If you are applying for a passport please register for the program and advise Inner Journeys of your new passport details prior to travel.

Room Type Preferred

Circle preference.

Single

Twin/Queen bedded

Share with ________________________________________________

Health

As some of the programs are conducted in remote locations and/or may feature workshops which highlight emotions, please indicate whether you have suffered any major emotional illness in the last five years or are under any medical or psychiatric supervision.

If you answer yes to any of these questions please specify below. Circle one. YES / NO

_________________________________________________________________________

_________________________________________________________________________

If appropriate, please also confirm in writing that you are fit to travel and enclose a doctor's certificate of fitness to travel.

 In case of emergency, whilst attending the program, please include
the name of a contact person.

Name____________________________________________________________________

Relationship to Participant _______________________________

Ph (Day)_____________________________________________

Ph (Eve)_____________________________________________

I have read and confirm my acceptance of Inner Journey's Booking Conditions
as detailed in the Inner Journey's Web Site.

Name____________________________________________________________

Signature _____________________________________ Date ___/____/_______

Payment Details

Banker's cheque or draft ________

Or Credit Card ______

Deposit $_______ per person x _____ persons $________________

Or full payment $___________________ x ______ persons @ $_____________

Total Payment $__________________

Credit Card Payment

Credit card: MasterCard ___ Visa ___ American Express ___

Name exactly as it appears on the card _______________________________________________

Card number ________________________________________ Expiry Date_____________________

Signature_____________________________________________________ Date ___________________