Application Form

Vipassana Healing Registration Form

Travel to John of God in Brazil with Barbara Brodsky and/or John Orr

Please print clearly or type

Session Start date  _1_/_25_/20___     Session End date  _2 / 09 /20___

Name____________________________________ Address__________________________________________ City____________________________________ State _____ Zip code ____________ 

Day Phone____________________ Evening Phone______________________ 

Passport Number ________________________________ Country of Issue ________ 

DOB___/ ___/ _______
Emergency contact ______________________________(relationship):_________________________ Phone_________________ E-mail_________________

Please describe your meditation practice, if any:


Medical Conditions*

I, hereby, state that the list below represents all medical conditions (physical, mental, spiritual, psychic and/or emotional) that I am being treated for by a medical doctor and/or other health
care practitioner and/or professional at this time. I, hereby, state that the list below also includes all physical, mental and/or emotional challenges I am dealing with that have not been treated but for which I am concerned. (If more space is needed, attach an extra page.) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

*I understand that if I am seriously ill I am required to send one (1) recent picture (frontal view) to be taken before the Entity for evaluation and permission to make the journey prior to joining a group. I understand and agree that Barbara Brodsky/ John Orr are not responsible for any health conditions or ailments contracted prior to, during, after or as a result of this journey.


I, hereby, state that the list below represents all medications I am taking that have been prescribed by medical doctors and/or health care practitioners and/or professionals AND all medications that have been prescribed but I have chosen not to take. (use back if needed) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Page 1 of 4

Special Requirements Advisory*

I have the following disabilities and will require the following special arrangements to be made for me during travel to, from and/or during my stay in Abadiânia (i.e., wheelchair, oxygen, special diet, etc.): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

*Please note, that while Barbara Brodsky, John Orr and their agents will make every effort to ensure the ease and comfort of group members, a personal assistant (for whom an application form must also be completed) must accompany persons requiring frequent/constant care.

Traveling with the Group

I understand and agree that if I arrive or depart at times which are different from the planned group arrival arrangements specified for the John of God – Cosmic Healing Journey I am joining, I am entirely responsible for transportation costs for travel to and from the airport or bus station of my arrival and/or departure, to and from Abadiânia.

Extra Luggage

If I bring more than two pieces of luggage and one carry-on, I understand and agree to pay any extra expense for the transportation for same for the duration of this journey.

Travel Insurance

I agree to supply proof of travel, health, hospitalization and hospital transportation insurance for this John of God - Vipassana Healing Journey within forty-five days of trip start. See our Vipassana Healing web site/ Vital Answers to Questions/ travel insurance.

Travel and Health Documents

I understand and assume all responsibility for obtaining a valid passport (valid for at least 6
months after the beginning date of my journey). I will personally get information about, apply for,
pay for and obtain all visas, inoculations, and other travel documents and requirements in compliance with the customs regulations of Brazil and my own country. I understand and agree
that these costs are not included in the cost of the journey. See the CosmicHealingMeditation website for further information about visas.

Trip includes:

• Pre-trip orientation and personal interviews in person or by telephone.   • Guidance on obtaining a visa and on travel plans. To the extent possible, the group will meet in the US and fly on to Brazil together, where Barbara or authorized taxi will meet you.   • Round trip taxi or chartered van transportation from the airport to Abadiânia (Ah-Bah- Jahn'-Ee-Yah), the central Brazil town where the Casa is located.  • Private standard room with bath in a lovely pousada (inn) for 13 nights, including 3 wholesome, delicious meals a day with vegetarian options.  • A starting large bottle of Casa water, blessed by the entities.  • Casa tour, and a crystal bath session on your first day.  • Escorted visit to the sacred waterfall.  • Guidance for your sessions with Medium João and the entities, and follow up on each session. We will accompany you through the Casa process and work with you with the translator.  • Group silent and guided meditations as appropriate.  • Personal and group interviews as needed.  • A group dinner during our weekend break. • Follow up once you return to the US.

Page 2 of 4

Not included:

Travel to Brazil, excess baggage, laundry, telephone calls, medical expenses, items of a personal nature, gratuities, your remaining Casa water and healing herbs as prescribed by the entities, souvenirs and gifts.

If your primary contact is Barbara Brodsky, make a check or money order out to Vipassana Healing for US $500.00 (non refundable registration fee) and send to Barbara Brodsky, 3455 Charing Cross Rd. Ann Arbor, MI 48108 USA (Telephone: 734-971-3455).

If your primary contact is John Orr, make a check or money order out to John Orr for US $500.00 (non refundable registration fee) and send to 2301 Hermitage Rd. Hillsboro, NC 27278 USA (Telephone 919-943-0438).

I agree to pay the balance of US$ 1,700.00 ($1,500 for returners) for my Vipassana Healing Journey within forty-five days prior to the official starting date of the journey for which I originally signed up. 10% of your total fee is offered to the Casa as a donation.

Cancellations and Re-scheduling by Barbara Brodsky
I understand and agree that Barbara Brodsky reserves the right to cancel or re- schedule journey schedules and substitute accommodations of a similar standard without refunding hotel charges or transportation penalties incurred.


I understand and agree that five-hundred dollars (US$500.00) of whatever deposits or payments I have made whether designated toward the reservation of space on this journey, paid as a deposit, as partial payment or as payment-in-full of the fees charged for the journey between the dates at the top of this Application Form is nonrefundable. However, I also understand and agree that under certain emergency circumstances, this amount may be applied to a future journey within a two year period.

I understand and agree that the cancellation deadline for this journey is thirty days prior to the starting date of the journey designated on this form. I also understand and agree that monies or fees, which I paid toward the tour, (except the US $500.00 non-refundable reservation fee), will
be refunded upon request if that request is received in writing 45 days or more prior to the scheduled original starting date of tour. Without this written request these monies and fees may
not be fully refunded due to cancellation fees charged to John Orr and Barbara Brodsky as a
result of last minute cancellations.

All fees will be returned (including reservation fee) if the Healing Journey is canceled by Barbara Brodsky or John Orr. However, Barbara and John do not accept nor assume any responsibility for charges incurred for flight, loss of luggage, room accommodations not part of our tour, cancellation charges or any other loss whether financial or otherwise incurred by said cancellation.

The Vipassana Healing Journey participant acknowledges that at no time did Barbara Brodsky, John Orr or their agents promise or imply any cure of the participant's medical condition. This trip is undertaken at the free will of the undersigned, without pressure by Barbara Brodsky or John Orr.

Page 3 of 4

I, hereby, affirm that I have read and fully understand all the information on this “Registration Form”. Signed:____________________________________________ Date: ___/ ___/ _____
I, hereby, declare all information and answers on this form accurate and true.
Signed: ___________________________________ Date: ___/ ___/ _____


Mail BOTH signed original application and deposit check payable to Vipassana Healing, to:

Barbara Brodsky 3455 Charing Cross Rd. Ann Arbor, MI 48108, USA (734-971-3455) Or:

Mail BOTH signed original application and deposit check payable to John Orr, to:

2301 Hermitage Rd. Hillsboro, NC 27278 USA (Telephone 919-943-0438).

Please keep a copy for yourself. This form and your deposit will reserve a place for you. Reservations are honored on a “first come” basis.

Upon receipt of your application, Barbara or John will call or email you to confirm your participation and further discuss your intentions and needs for this trip.

page4image8784 page4image8944

Page 4 of 4