Please complete the form below to forward your Cambodia Workshop application

Date of Birth:
Street Address, including City. State/Province & Country Code
Home or Mobile Phone:
Please include Country Code and/or Area Code
Work Phone:
Please include Country Code and/or Area code
How were you referred to us?:
Passport Exp. Date:
Special Dietary Needs:
Attend Workshop
Health Concerns or Allergies:
Emergency Contact:
Include Name, email, phone number & mobile phone number
Name of Traveling Companion:
Companion Phone:
Flight Arrival Date:
Flight Departure Date:
Single/Double Occupancy
Please note that single occupancy rooms are limited and may not be available for all registrants. Contact us for more information.
I Accept
I Do Not Accept
Release and Assumption of Risk I am aware that during this trip I am participating under the arrangement of Mindful Alliance Center. Certain risks and dangers may occur including but not limited to the hazards crossing mountains, accident or illness in remote places without medical facilities or means of rapid evacuation, the dangers of civil disturbance and war, the forces of nature and travel by air, automobile, bus and other conveyance. In consideration of the right to participate in such a trip and the services of Mindful Alliance Center, I have and do hereby assume all of the above risks and will hold them harmless from any and all liability actions, causes of actions, debts, claims of demand of every kind of nature whatsoever which I now have or which may arise of or in connection with my participation on this trip. The terms thereof shall serve as a release and assumption of risk for my heirs, executors, and administrators and for all members of my family. I acknowledge that I have been advised that California has a Travel Consumer Restitution Fund and that my tour is not covered by that law because the foreign providers of transportation and travel services utilized for this tour are not registered as Sellers of Travel in California. I understand that I am not eligible to make any claim against that fund.

Digital Signature:
I understand that there is a minimum number of registrants required for each trip to go forward and that if a trip is canceled due to insufficient numbers and I have used a credit card to pay for the program, a full refund will be given, less administrative fees.
Enter the code below in here: