Immersion Registration Form - Alternate Payment Options

Therapeutic Immersion: Registration Form

To reserve your place in this upcoming event, please complete the registration form below.
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Event I'm Registering For

Therapeutic Immersion - Bali (Oct 9 - 12, 2018)Body, Mind & Spirit: Yoga Trek Nepal 2019Other (list below)
Dietary Requirements
Other Event
I'd like to pay my deposit

EFTPOS/Credit Card in person (at PhysiYoga)Electronic Funds TransferCash or Cheque
Any other questions or comments?
Should be Empty:

Therapeutic Immersion: Registration Form