Immersion Registration Form - Credit Card Book & Pay

Therapeutic Immersion: Bali

Please complete this booking form to secure your place in our Therapeutic Immersion to Bali
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Any Particular Questions or Concerns?
Dietary Requirements?

My Products

Akasha (Yoga Stream) - Payment Plan EARLY BIRD$222.50AUD

Akasha (Yoga Stream) - Full Payment EARLY BIRD$890.00AUD

Akasha (Yoga Stream) - Full Payment REGULAR$990.00AUD

Chikitsa (Therapy) Stream - Payment Plan EARLY BIRD$372.50AUD

Chikitsa (Therapy) Stream - Full payment EARLY BIRD$1,490.00AUD

Chikitsa (Therapy) Stream - Full Payment REGULAR$1,600.00AUD

Single Supplement$250.00AUD

Child - 6+$295.00AUD

Quantity

Child 3 - 5 Years $90.00AUD

Quantity

Subtotal $0.00AUDTax $0.00AUDTotal $0.00AUD

Therapeutic Immersion: Bali