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 ____________ E-mail_________________________________________ Passport Number ________________________________ Country of Issue ________ DOB___/ ___/ _______ Please describe your meditation practice, if any: ____________________________________________________________________
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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 *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. Medications 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 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. Fees 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 Refunds 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 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: ___/ ___/ _____ Instructions: 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. Page 4 of 4 |