Booking Which retreat are you wanting to book?*Please advise of month, destination and artist. Title Ms Mrs Dr Your full name (as it appears on your passport):* First Last Do you have a nickname or a first name you prefer to be called? Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Postal Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone number*Name and contact number of next of kin (emergency contact only): Relationship to you: I am travelling: On my own With a friend or family member Name of friend or family member Please advise us of 3 things you really detest?Please tell us 2 things you'd love to do during your Art Escapade?Meal requirements and/or allergies* I do not have any specific dietary requirements or allergies I have the following specific dietary requirements/allergies Dietary requirements:What is your blood group?* Medical conditions*Please indicate if you have any serious health issue that may affect your travel insurance coverage, your physical capacity to undertake some activities on the retreat or may otherwise need to be considered. I have no specific medical condition I have the following medical condition/s Medical condition(s)Medical Information:*Our tours and retreats do require some physical exertion, please tick what best suits you below. You are unable to walk on uneven surfaces unaided. You require assistance getting on an off various modes of transport. You are able to walk on uneven surfaces unaided and you do not need any foreseen assistance though out the Tour/Retreat You are able to walk on uneven surfaces unaided and enjoy activities that require more strenuous exercise. Travel insurance*We strongly recommend that at the time of your deposit you purchase a comprehensive travel insurance policy of your choice. Please note that passengers without travel insurance will not be able to join the retreat. Please advise of your Travel Insurance Policy details if available. I want to advise of my Travel Insurance Policy details now I will provide Travel Insurance details at a later date Your name: Insurance Company Policy Number Date of Issue Terms & Conditions PLEASE READ CAREFULLY AND TICK THE BOX*A deposit of $1000 per person is required to confirm your booking on a retreat. Final payment of the retreat fee will be due 6 weeks before the commencement of the retreat. Where bookings are made less than 6 weeks before the commencement of the retreat full payment must be made at the time of booking. A retreat may not proceed if less than 6 guests are confirmed. A maximum of 8 guests is accepted at each retreat. I accept the Terms and Conditions on this booking form DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I would like to receive news and special offers via email Yes please No thank you TweetShare
