| Your Full Name | |
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| Zip/Postal Code | |
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| E-Mail Address | |
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Emergency Contact Information |
Name
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Relationship
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Home Phone
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Mobile Phone
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If using this form for one family or group please supply the requested information for all members of the group.
Roommate Selection:
Roommate Name for Cabaña (many can accommodate more than two people should you want to share with a larger groups of friends or family)
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| Roommate Name(s) |
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As this program involves travel and different climates, we want to have some basic health information before any problems develop.
Please list any medical conditions you have: |
| Medical Conditions |
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| Food or Medication Allergies |
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Retreat Options & Lodging Choices and Fee calculation:
This traveling group begins with 4 days and three nights at a private hot springs resort, and then moves to a private villa estate at Playa Coco. Each location has local healing benefits like natural volcanic mud, salt filled waters, UV exposure, mineral laden waters, steam treatments and unbeatable Natural Wonders of animals, plants and geology.
Therapeutic Tranquil Tropical Psoriasis Retreat
7 days 6 nights Double Occupancy (or more) hotel rooms or cabañas
includes meals and local transportation during the retreat. |
Participant Fee
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$1,800 pp/USD for participants
(includes private treatments with Deepa) |
Guest Fee
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$1400 pp/USD for guests (without private treatments with Deepa) |
Total Fees
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.0825 Tax for CA residents
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Grand Total
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You will recieve confirmation once this amount is received |
Enter Your Name in Lieu of Signature
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I
freely request admission to the Summer 2010 Psoriasis retreat and any optional side trips offered by Deepa Health Farm, SA in Costa Rica, June 26 ---July 2 , 2010. I am a responsible adult and I will take full legal and financial responsibility for my own actions and travel arrangements to and within Costa Rica. Parents agree to be responsible for their children's behavior and actions. I will not hold Deepa Health Farm or its agents, sub contractors and representatives responsible for any actions in accordance with all the laws of Costa Rica, Central America. By submitting this form, I am agreeing to this statement. |
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Please send a money order or cashiers check made out to Deepa Health
C/O M. Gleason, 300 Long View Lane, San Luis Obispo, California, 93405 |
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EMF Email Form