CANADA RETREAT REGISTRATION FORM If you need additional time to fill in this form, look for the 'save and continue later' link at the very bottom of the form. This will allow you to come back and fill in the rest of the form later. Basic InformationYour name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone number*Have you practiced Yuan Gong before?* Yes No Please provide details:How did you hear about this retreat? Would you like to volunteer some of your time with the preparation of the retreat?* Yes No Will you be purchasing the book “Wellbeing begins with you”?*(This is to help us plan our inventory.) No Yes About how many copies will you need? Transportation & MealsHow will you be traveling to Water Valley?* I'll be driving myself (or riding with a friend) I need transportation (and can share in driving expenses) Can you give someone else a ride? I'm happy to transport someone else (who would share in driving expenses) Do you need special accommodations for meals?* No Yes Please indicate your dietary restrictions: Gluten free Dairy free Vegan Accommodations & PaymentThe majority of the lodging is shared rooms with bunkbeds, which will accommodate up to 4 people. There are a limited number of single or double occupancy rooms available which have either two twin- or two bunkbeds. These are offered on a first-come, first-served basis. All rooms have shared bath.Select your accommodations: CDN$1,200: Shared room (up to 4), shared bath. CDN$1,445: Double room (price is per person), shared bathroom CDN$1,690: Single room, shared bathroom HiddenEarly registration discountYour registration fee will be adjusted according to the following schedule. Pay your registration in full by: • March 23, 2018 to qualify for a $100 discount Full payment must be received by April 2, 2018 to keep your reservation. March 23, 2018 Discount DiscountsIf you have been given a discount code, please enter it below. If your code is valid, you will see the price reduction reflected below. Teacher discount Price: Would you like to pay the full amount today, or just a deposit?A non-refundable deposit of CDN$200 is required to secure your reservation until April 2, 2018 when full payment will be required, or you may elect to pay in full now. Pay the total today Just pay the CDN$200 deposit today Balance which you must pay to complete your registration:See above for the date by which we must receive your complete payment. Full payment by Jan 22 or March 23 is required to qualify for the $200 or $100 early registration discounts. Price: $ 0.00 CAD Total to pay today: Price: $ 0.00 CAD How do you wish to make today's payment? Secure online payment using my credit card I will mail in a check I'd like to use PayPal Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Payment instructions Please make out your cheque to "Sabine Goubau" and mail it along with a printout of the confirmation email you will receive from us to: Sabine Goubau 2812 7 Ave NW Calgary, AB, Canada T2N 1A9 Emergency ContactWho should we contact in case you require emergency attention during the retreat?Name* First Last Relationship Phone Number*Medical BackgroundRen Xue of the Americas will not share this information with anyone other than retreat staff and/or medical professionals called to assist with a health care emergency.Do you have any disabilities that might affect your ability to participate in the activities at the retreat?* Yes No E.g. great difficulty moving, sitting, seeing, hearing, or listening?Please describe your physical challenges below.*Have you had, or do you now have, any psychological conditions that could affect the safety and wellbeing of yourself or others?* Yes No Please supply some details about your psychological history below.*Do you have any medical conditions that would be helpful for us to know about?* Yes No Please supply details regarding your medical condition(s) below.*NOTE: If you are taking prescription medications that we would need to know about in the event of a medical emergency, please bring a list to the retreat in a sealed envelope (with your name on the outside) for us to keep on file. It will be opened only in the case of an emergency and destroyed after the retreat. Certain medical (either physical or psychological) conditions may require that we speak with you before accepting your registration. If this pertains to you, we will contact you within three days of your registration, so please do not book travel arrangements until three days after you complete this registration form.Cancellation PolicyCancellation Policy 2018 Ren Xue Retreat in Water Valley, Alberta If you need to cancel your retreat registration, please do so at your earliest convenience. Late cancellations make it difficult to give someone else the opportunity to attend. Once you have paid any portion of the registration fee, administrative and cancellation fees will apply as follows: Cancellations on or before March 23 Registration fees less the $200 deposit and applicable administrative charges (PayPal, credit card, bank etc.) will be refunded by cheque within 30 days. Cancellations after March 23 Registration fees are non-refundable In the case of a serious emergency (hospitalization or death in the family), we will credit you 50% of the refundable fees. Refundable fees are fees less the $200 deposit and applicable administrative charges (PayPal, credit card, bank etc.) Exceptional Circumstances Ren Xue of the Americas reserves the right to request a participant leave the retreat if the participant's behavior is deemed to be either excessively disruptive or dangerous to self or others. In this case, all retreat fees are non-refundable. In the highly unlikely event that Ren Xue of the Americas must cancel the retreat for any unforeseen reasons, we will notify all registrants as soon as possible and will refund the full fee amount paid including the deposit by cheque. Refund policy* I have read and agree to the above policy NameThis field is for validation purposes and should be left unchanged. Δ
