Adirondacks: Yoga and Hiking in the High Peaks

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1 Welcome

2 Choose your lodging package

4 Tell us about yourself

Phone (daytime) *
Address line 1 *
Address line 2
City or region *
State or province *
Zip or postal code *
County
Country *
I identify my gender as: *	Your answer will support gender-based shared room assignment. If you identify as trans, non-binary, neutral, or otherwise genderqueer and are sharing a room, please select a gender that you are most comfortable sharing a room with. Please contact us in advance of your arrival or call 1-800-822-4547 if you have any questions or concerns.
Personal Expression
Birth Date *
Requested Roommate	Please indicate the name(s) of your mutually, prearranged roommate(s) and ensure all parties are registering in the same room type. Delay in the submission of any roommate’s registration may result in the roommate request not being able to be fulfilled. If you do not inform us in advance of your roommate choice, we will pair you with another solo traveler roommate(s) of the same gender.
How did you hear about this program? *	Himalayan Institute Website Himalayan Institute Email Social Media Other (ie. teacher/friend/etc)
Other:
Is there anything else you feel would helpful for us to know?	(ie. dietary, sleep, mobility or other health considerations)

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5 Emergency contact

Emergency contact name *	First and last name of a person NOT TRAVELLING WITH YOU.
Emergency contact relationship *	What is your relationship to your emergency contact? For example, "Contact is my father".
Emergency contact daytime phone
Emergency contact mobile phone *
Emergency contact home phone
Emergency contact email *
Emergency contact address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *

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6 Participant Responsibilities

Trip Cancellation Insurance *	It is my responsibility to research and select a trip cancellation plan that meets the needs and requirements of the program for which I am registering. I understand the Himalayan Institute strongly recommends all participants purchase insurance; and should I choose not to purchase insurance, or need to cancel my registration before purchasing insurance, no exceptions will be made to the Cancellation Policy as stated in the Application/Agreement’s Terms and Conditions.
Payment of Balance in Full: *	It is my responsibility to ensure my balance is paid in full by the regular registration closing date and I understand that failure to do so will result in my registration being canceled; refunds will be made in accordance with the Cancellation Policy as listed in the Terms and Conditions section of the Application/Tour Participant Agreement.
Dietary *	It is my responsibility to discuss any additional dietary concerns before registering or promptly upon registration as I understand that only vegetarian meals with limited vegan and gluten-free options will be provided.
Health *	It is my responsibility to ensure I am of good physical, mental and emotional health to partake in this program. I attest that at the time of this registration, and as per my physician(s) approval (where applicable), I am of appropriate good health as named above for participation in this program. Should my state of good health change prior to the start date of the program for which I am registering, it is my responsibility to notify the Himalayan Institute in writing as soon as possible, and should I need to cancel my registration due to this change in my health, I understand that the Cancellation Policy as listed in the Terms and Conditions section of the Application/Agreement will apply.

7 Agreements

Payment Authorizations *	Yes, I authorize the Himalayan Institute to charge my credit card for the balance due at the EARLY RATE on the published payment deadline for this registration Yes, I authorize the Himalayan Institute to charge my credit card for the balance due at the REGULAR RATE on the published payment deadline for this registration No, I do not authorize the Himalayan Institute to automatically charge my credit card for the balance due
Share contact information *	YES - please share my contact information NO - do not share my contact information If you choose YES, your name, email address, city and state of residence will be shared with other excursions participants so we can connect regarding travel, packing, and other excursion preparations.
Adirondacks Yoga and Hiking Tour Participants Agreement *	I have read and understand the Tour Participant Agreement for Adirondacks: Yoga and Hiking in the High Peaks (Land Only) and by making my advance payment as set forth below, agree to the terms thereof. I understand that violation of the excursion policies is cause for immediate dismissal from the excursion.Read the Tour Participant Agreement .
Participant Signature *	Electronic Signature: Type your name to sign this application.
Received Copies of	Visa Passport Photo
Flight Information Received	Yes No
Attending an add--on, Pre or Post	Pre Post
Other Medical Disclosures
Dietary Needs
Extended Stay? ( If Yes what are the dates)
Extension Payment -If not paid, amount due upon arrival:	Yes No(Supply Amount)
Mobile Number in India if available
Registration Type:	Individual Couple Family (parent) Family (child)
Country of Visa	India Other
Parent Name(s)
Child's Gender
Insured's Name
Insurance Company
Policy ID Number
Insurance Company Phone
Consent Signed by Parent(Check for Yes)	Yes No
Date Consent Signed

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8 Confirm your registration

Discount code

Sub Total	$0

Donations	$0

Taxes	$0

Deposit	$0

Pay	Choose to pay a deposit or the full amount right now.

Due Now	$0 $0

First Name
Last Name
Card Type
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

Adirondacks: Yoga and Hiking in the High Peaks

1 Welcome

2 Choose your lodging package

3 Additional Programs

Participants

4 Tell us about yourself

5 Emergency contact

6 Participant Responsibilities

7 Agreements

Tour Participant Agreement

8 Confirm your registration