India 2008 REGISTRATION FORM 2^nd Part

From March 17^th – 4^th with Camel Extension to April 8^th

With Ernesto ORTIZ and Eric GRANGE

Please use an additional page if you need to provide more information

Date:________________________________

Name:________________________________________________________________________

Address:______________________________________________________________________

State / Country:________________________________________________________________

Home phone number:____________________________________________________________

Mobile phone number:___________________________________________________________

Email:________________________________________________________________________

Occupation:___________________________________________________________________

If you desire to share your room with a person you already know please provide:

Name of the person:_______________________________________________

• Type of room you are requesting: Circle one

Double Occupancy (2 single beds) or Single Occupancy (1 Queen size bed)

Please provide us with any information about your health that we must be aware of:

Please let us know if: You have ever attempted suicide, if you are under psychiatric care or have been hospitalized for mental disorders, if you suffer from schizophrenia or epileptic seizures?

Please provide the following information:

• Contact person in your hometown: _____________________________________

• Relationship: ______________________________________________________

• Emergency telephone number: ________________________________________

IMPORTANT: Please provide a photocopy of your passport when you submit your registration

Please acknowledge that Journey to the Heart and Oasis, Ernesto Ortiz and Eric Grange do not provide insurance for this tour. You are responsible for taking travel and health insurance of your own.

_______ (Initial here)

I understand that Journey to the Heart workshops are processes designed to assist me in “self‑exploration” and “self‑healing”. I further understand that these workshops are direct experiences and, though educational in nature, are not tretment or therapy. They are not intended to be used to replace any treatment or therapy which may be appropiate for any person.

In consideration of participation in Journey to the Heart workshops, I herby release and forever hold harmless and indemnify Ernesto Ortiz, Journey to the Heart, Eric Grange, Oasis, other facilitators, assistants, agents, successors and assigns which I may now have or have at any time in the future.

Signature:________________________________________________