Shamanic Travel Adventures

REGISTRATION FORM:

To register your intention to participate in the Shamanic Travel Adventure, please fill all fields then click the SUBMIT button.

I choose to participate in the following Shamanic Travel Adventure:

Adventure

Email Address

Name:
Address:
City:
State:
Zip:
Country:
Phone:

Date of Birth:
Time of Birth:
Place of Birth:

Passport #
Country of Passport Issue

Emergency Contact Person
Emergency Contact Phone #

Existing Medical Condition (y/n)	Yes No
Are you taking any Medications	Yes No
If Yes to either, Detail (in case of emergency)

A deposit of $1,000 deposit is due upon Registration. Payment must be made with a Cashier's Check (sorry, no personal checks), made out and sent to: Jade Wah'oo Grigori PO Box 4448 Sedona, Az 86340 USA No other form of payment will be accepted for Shamanic Travel Adventures. The $1,000 deposit is non-refundable. If Jade Wah'oo Grigori should for any reason cancel a Shamanic Travel Adventure all deposits and payments will be returned in full.

My electronic signature, below, is a legal signature: Signed: Date:

Submit form, then send payment.

For any other questions contact Jade at:

928-284-0110
JadeWahoo@Shamanic.net