Location of Retreat 1 : : Please Select Please Select  1 : : Dolphin Bay, Ballina Dolphin Bay, Ballina   1 : : Telo Islands, Western Sumatra, Indonesia Telo Islands, Western Sumatra, Indonesia  1 : : East Java,Indonesia East Java,Indonesia  1 : : Remote Mentawi Island Remote Mentawi Island  1 : : Santosha at Little Beach, Tasmania Santosha at Little Beach, Tasmania 

Date of Retreat 1 : : Please Select Please Select  1 : : 3rd October 2011 - 7th October 2011 3rd October 2011 - 7th October 2011  1 : : 18th December 2011 - 23rd December 2011 18th December 2011 - 23rd December 2011  1 : : 17th Feb 2012 - 20th Feb 2012 17th Feb 2012 - 20th Feb 2012  1 : : 11th March 2012 - 18th March 2012 11th March 2012 - 18th March 2012   1 : : 22nd March - 26th March 2012 22nd March - 26th March 2012  1 : : 12th April 2012 - 17th April 2012 12th April 2012 - 17th April 2012  1 : : 4th May 2012 - 11th May 2012 4th May 2012 - 11th May 2012  1 : : 10th July 2012 - 19th July 2012 10th July 2012 - 19th July 2012  1 : : Ongoing 2011 + 2012 Ongoing 2011 + 2012  

Date of Discount Retreat 1 : : Please Select Please Select  1 : : 12 February 2012 - 15 February 2012 12 February 2012 - 15 February 2012  1 : : 16 February 2012 - 19 February 2012 16 February 2012 - 19 February 2012  1 : : 19 April 2012 - 22 April 2012 19 April 2012 - 22 April 2012  1 : : 10 May 2012 - 13 May 2012 10 May 2012 - 13 May 2012  1 : : 18 June 2012 - 21 June 2012 18 June 2012 - 21 June 2012  1 : : 30 August 2012 - 2 September 2012 30 August 2012 - 2 September 2012  1 : : 1 November 2012 - 4 November 2012 1 November 2012 - 4 November 2012  1 : : 1 December 2012 - 4 December 2012 1 December 2012 - 4 December 2012 

Second Preferred Date of Discount Retreat 1 : : Please Select Please Select  1 : : 12 February 2012 - 15 February 2012 12 February 2012 - 15 February 2012  1 : : 16 February 2012 - 19 February 2012 16 February 2012 - 19 February 2012  1 : : 19 April 2012 - 22 April 2012 19 April 2012 - 22 April 2012  1 : : 10 May 2012 - 13 May 2012 10 May 2012 - 13 May 2012  1 : : 18 June 2012 - 21 June 2012 18 June 2012 - 21 June 2012  1 : : 30 August 2012 - 2 September 2012 30 August 2012 - 2 September 2012  1 : : 1 November 2012 - 4 November 2012 1 November 2012 - 4 November 2012  1 : : 1 December 2012 - 4 December 2012 1 December 2012 - 4 December 2012 

Booking agency accommodation voucher number

Booking agency accommodation redemption number

Booking agency activity voucher number eg.Surfing

Booking agency activity redemption number eg. surfing

Surnames of others travelling in your group

Last name  *

Email  *

Confirm email

Phone  *

Address  *

City / town  *

State / region  *

Post / zip code  *

Country  *

Occupation  *

Gender  * 1 : : Male Male  1 : : Female Female 

Do you speak English?  *   

Do you need an interpeter for the duration of teacher training?  * 1 : : Yes Yes  1 : : No No  1 : : Please select Please select 

Are you travelling with friends who speak English?  * 1 : : Please select Please select  1 : : Yes Yes  1 : : No No 

Are you a YogaTeacher? 1 : : Yes Yes  1 : : No No 

Why are you interested in a Retreat?

What do you hope to gain, learn, or focus on during the retreat?

Do you have any comments or questions?

Do you currently or have history of, suffering from an eating or exercise disorder? 1 : : Yes Yes  1 : : No No 

Do you use drugs? 1 : : Yes Yes  1 : : No No 

Do you smoke? 1 : : Yes Yes  1 : : No No 

Do you drink alcohol? 1 : : Yes Yes  1 : : No No 

Do you have any challenges in participating in physical activities? 1 : : Yes Yes  1 : : No No 

Do you have any current or past injuries? 1 : : Yes Yes  1 : : No No 

Do you require assistance during the course due to the above injury or medical condition? 1 : : Yes Yes  1 : : No No 

Do you have any special dietary requirements 1 : : Yes Yes  1 : : No No 

If you answered YES to any of the above, please give details

Emergency Contact phone (please include area code and country code)  *

Please select a payment option 1 : : Please select Please select  1 : : Direct Deposit Direct Deposit  1 : : Paypal Paypal  1 : : Money Order Money Order  1 : : Personal Cheque/Check Personal Cheque/Check  1 : : Credit Card Credit Card 

Card Number

Valid from

Expiry date

Security number (3 digits on reverse)

I agree that I must communicate with my teachers, at any time if I feel unwell or injured during the course.

I agree and understand it is my responsibility to ask my teachers if I do not understand any particular concept that is taught during the course.

I understand that drugs are not permitted on the onsite Accommodation or the Yoga Shala.

I understand that if I consuming any type of drug during the Training, such as marijuana, cocaine, etc, Santosha has the right to ask you to leave the course.

I agree that photos taken by Santosha during the course may be used for other purposes such as advertising

I agree that once the course has commenced Santosha can not refund any monies. If the situation has extenuating circumstances, Santosha will gladly discuss this further.

I have printed, signed and sent the form/s in

I understand that no one can participate in the retreat until the form/s is/are received and verified by Santosha Yoga

If you have not downloaded the form, please let us know when you will do so

I have read and understood all terms and conditions that apply for the retreats

   

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