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 __/___/20___ Session End date __/___/20___
Name____________________________________ Address__________________________________________ City____________________________________ State _____ Zip code ____________
Passport Number ________________________________ Country of Issue ________
DOB___/ ___/ _______
Please describe your meditation practice, if any:
____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________
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 is 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) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________
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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.
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.
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
• Pre-trip orientation and personal interviews in person or by telephone.
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• A group dinner or trip to a local ranch during our weekend break. • Follow up once you return to the US.
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 John Orr, make a check or money order out to John Orr for US $500.00 (non refundable registration fee) and send to 2301 Hermitage Rd. Hillsboro, NC 27278 USA (Telephone 919-943-0438).
I agree to pay the balance of US$ 1,400.00 ($1150 for returners) for my John of God – 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 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 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 fifteen 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 However, Barbara does 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 or her 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.
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I, hereby, affirm that I have read and fully understand all the information on this “Registration Form”.
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.
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