Bali 2018 Registration Form

February 18 - February 24, 2018
7 days | 6 nights

To reserve a spot, please 1) Fill out and submit this form AND 2) Venmo $750 deposit. Registration is complete only after receiving these 2 items. 

Name *
Name
Contact Phone Number *
Contact Phone Number
Address *
Address
Date of Birth *
Date of Birth
(And How Related)
Emergency Contact Phone Number *
Emergency Contact Phone Number
(All prices in USD currency.)
(Name of person.)
(Note: This villa only serves vegetarian cuisine. No meat or seafood.)
Waiver + Payment
Please read all clauses.
ASSUMPTION OF RISK, HEALTH WARRANTY, RELEASE, & WAIVER OF LIABILITY: *
RELEASE AND WAIVER OF LIABILITY: *
Non-Refundable Deposit *
Final Payment *
By typing in your name, your e-signature is acceptance, agreement and legally binding to this waiver and to the non-refundable deposit.
Optional Questions
(For those who are newer to yoga or to practicing with me, kindly answer the following questions so that I can get to know you and your practice more.)

To complete your registration, please Venmo $750 deposit to Cooper Chou Yoga (AC C @AC-Yogi) below!