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SACRED INDIA TOUR 2020   
REGISTRATION FORM
 
This form can be printed out and submitted by post. Or you can scan it and send the digital version to: divyanandama@gmail.com.
 
 
 
 GENERAL INFORMATION
 
 Name (as it appears on your passport):
 
 ____________________________________________________________

Spiritual name or name you usually go by

_____________________________
 
Address_________________________________________________________
 
City _______________________State _________ Zip code_________
 
Phone (home) _____________________( cell)______________________
 
E- Mail address _______________________________________________
 
Age _____ Gender: M ____F___

Occupation__________________________
 
 
EMERGENCY CONTACT PERSON
 
 
 
Name __________________________City & State_________________
 
 
Daytime phone ________________Evening Phone____________________
 
 
Cell phone ___________________Relationship to you________________
 
 
YOGA BACKGROUND
 
 How long have you practiced Hatha Yoga? ________
 
Which style of Hatha Yoga are you accustomed to?_________
 
Do you practice daily Meditation?   Yes_______ No _________
 
If yes, for what duration each day? _________
 
 
HEALTH RECORD
 
 Have you had or do you now have:   (please circle if so)
 
 
Measles                                                                              Frequent headaches
 
Mumps                                                                                Frequent sore throats/colds
 
Smallpox                                                                             Difficulty sleeping
 
Rheumatic fever                                                                  Earaches
 
Pleurisy                                                                                Chronic cough
 
Bronchitis                                                                             Cancer
 
Tuberculosis                                                                         Shortness of breath
 
Hepatitis                                                                               Heart trouble or BP
 
Mononucleosis                                                                        Frequent indigestion
 
Typhoid fever                                                                        Difficulty of urination
 
Epilepsy                                                                                  Back problems
 
Hernia                                                                                     Fainting spells
 
Dermatitis                                                                               HIV or AIDS
 
Stomach ulcer                                                                          Eating disorder
 
Kidney trouble                                                                          Car sickness
 
Diabetes                                                                                    Obesity
 
 
 
Any others? (If so, what?)___________________________________ 
 
Please describe details of any you circled on the back of the third page - or if you're sending a digital copy, send details in a separate email.
 
Have you been under the care of a hospital in the last two years? Yes ___No___
 
Hospital_____________________Disease________________Year__________
 
Hospital_____________________Disease________________Year__________
 
Have you ever been institutionalized for any mental disorder, nervous break-down,
 
 etc., or been under the care of a psychiatrist? Yes _______No ____
 
Have you ever had a serious injury ? Yes _______No ____
 
(if yes, specify)___________________________
 
 Are you currently taking any medications? Yes___________No ____
 
 (if yes,specify)_________________________________________________
 
 Agreement
 
 I agree to abide by the guidelines of the tour program, which include following a lacto-vegetarian diet and refraining from the use of alcoholic beverages, cigarettes or recreational drugs during the duration of the tour. I certify that I am in good health and have no physical or mental ailments, except as may be indicated on this application. I further agree to assume full responsibility for any injuries, losses or damages that may occur to me or my property during the tour.
 
 
Signature ____________________________Date____________________
 
 
If you wish to submit the registration form by post, please mail to: 
 
Swami Divyananda c/o Harpet
800 W. River Road
Tucson, AZ  85704
 
 
FEES AND DEPOSIT
 
 
The total fee for the tour is US $2200. The deposit required by October 1, 2019 is US $700. The second payment of $1500 is due December 15, 2019.
 
Do you wish for single room accommodation?  Yes _____ No ____  If yes, please add $375 to your deposit.

Checks are to be made out to Sacred India Tours and posted to:
 
Swami Divyananda c/o Harpet
800 W. River Road
Tucson, AZ  85704


 CREDIT CARD PAYMENTS:
 
If you prefer to pay by credit card you can use the Paypal button below (Labeled “Buy Now”).  For Paypal there is a 3% surcharge and your deposit will be $721. 
We also welcome payments made through Zelle or interbank transfer. 
 
 
 
 
 

If you do not have funds in the form of US dollars please contact Swami Divyananda for alternate arrangements. 

 We look forward to hearing from you!  Thank you.
 
OM SHANTHI, SHANTHI, SHANTHI
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