Option 2: Merge Holiday Option 2: Merge Holiday Application Form Step 1 of 6 16% Price (This price is included transfer fee from Payapal) Full Price : 13, 900 THB Early Bird Price Pay Before 30 May 2020 : 12, 000 THB *ACCOMMODATION, BREAKFAST, SURF TRAINING & 1 DAY TRIP TO NUSA PANIDA INCLUDED Date: 24-26 July 2020 Personal InformationName* First Name (required) Middle Name Last Name Nationality*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweAge*Gender*MaleFemaleSpoken Language Occupation Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Phone*Email* Emergency Contact Name* Emergency Contact Email* Emergency Contact Phone*Relationship Health InformationDo you have any health issues?* Yes No If yes, please describe Are you undergoing Medical treatment?* Yes No Do you have any Mental illness ?* Yes No If yes, please describe Are you pregnant?* Yes No Do you have any Injuries?* Yes No If yes, please describe Yoga ExperienceHow long have you been practicing Yoga ? How often (per week) do you practice ? What style of yoga do you practice? Do you do self-practice at home ?* Yes No How often you do your self practice? Have you ever practiced Ashtanga Yoga ?* Yes No For how long ? Have you ever practiced the Primary Series ?* Yes No Do you call yourself a Beginner, Intermediate, or Advanced ?*BeginnerIntermediateAdvancedHave you taught yoga before ? Yes No How did you find us?How did you find us? Facebook Google Website Friend Your Yoga Teacher Who is your friend? Who is your Yoga Teacher? What is the reason that you choose to train with Bright Yoga ?What is the reason that you choose to train with Bright Yoga ?* Our Quality Our Teachers Our Yoga School Style of Yoga Yoga Alliance Accredited Location Reasonable Price Timing of the course Other Other. Please Describe What program are you expecting to attend ?What program are you expecting to attend ?*50Hrs Merge Yoga Holiday in Bali JulyRocket 100hrs Indonesia Bali Its Yoga Satellite, Komune Resort and Beach ClubYin Yoga Retreat an Introspective Journey: 11 May - 19 May 2019 at Krabi ThailandROCKET INTENSIVE AND 100HRS TEACHER TRAINING PHILIPPINES, SIARGAO: 19- 23 May, 2019 (Rocket Intensive)ROCKET INTENSIVE AND 100HRS TEACHER TRAINING PHILIPPINES, SIARGAO 24- 28 May, 2019 (Become a Rocket Teacher)Ashtanga Yoga Teacher Training Toward 200hrs Yoga Alliance Certification. Indonesia Bali, Komune Resort and Beach Club 11- 20 July, 2019Ashtanga Vinyasa Yoga Fundamentals. 18- 20 September 2018, ThailandAshtanga 100hrs Indonesia Bali at Gaia Retreat Center : 2 – 9 July 2019Ashtanga Yoga Teacher Training 300hrs Yoga Alliance Certification. Thailand 2018 : 1 September- 30 November, 2018Will you attend this course alone?* Yes No Will you come with a friend or family?* Yes No If so, How many?If the course that you expect to attend is fully booked, will you be happy to attend another one ?* Yes No Which course is your second option ?*Yin Yoga Retreat an Introspective Journey: 11 May - 19 May 2019 at Krabi ThailandROCKET INTENSIVE AND 100HRS TEACHER TRAINING PHILIPPINES, SIARGAO: 19- 23 May, 2019 (Rocket Intensive)ROCKET INTENSIVE AND 100HRS TEACHER TRAINING PHILIPPINES, SIARGAO 24- 28 May, 2019 (Become a Rocket Teacher)Ashtanga Yoga Teacher Training Toward 200hrs Yoga Alliance Certification. Indonesia Bali, Komune Resort and Beach Club 11- 20 July, 2019Ashtanga Vinyasa Yoga Fundamentals. 18- 20 September 2018, ThailandAshtanga 100hrs Indonesia Bali at Gaia Retreat Center : 2 – 9 July 2019Ashtanga Yoga Teacher Training 300hrs Yoga Alliance Certification. Thailand 2018 : 1 September- 30 November, 2018Rocket 100hrs Indonesia Bali Its Yoga Satellite, Komune Resort and Beach ClubWill you attend this course alone?* Yes No Will you come with your friend or family?* Yes No If so, How many?Any additional Message How would you like to make the payment ?How would you like to make the payment ?* Paypal Bank Transfer PaypalWould you like to make the Paypal payment now?* Yes No 50Hrs Merge Yoga Holiday in Bali July*Deposit $1,566.00 USDEarly Bird Price Pay Before 1st JUN 2019 $5,220.00 USDEarly Bird After Deposit $3,654.00 USDFull Price Pay Before 15 JUL 2019 $5,742.00 USDFull Price After Deposit $4,176.00 USDExpected date of your payment ?* MM slash DD slash YYYY Amount of your deposit ?*Bank TransferName of Bank : KASIKORNBANK Swift Code : KASITHBK Bank Address : 1 Soi Rat Burana 21/1 Rat Burana Road, Khwaeng Rat Burana, Khet Rat Burana, Bangkok, Thailand, 10140 Fax: +6628888882 Tel.: +6628888800 Account Number : 3912855308 Account name : Kunkanit Phrombut Bank Branch : Central Rattanathibed *** Kindly e-mail us a photo or scanned copy of your transaction receipt. Terms and requirementsI am aware that the participation in the physical activity of yoga may result in accident or injury. I assume the risk and responsibility with the participation in this Yoga Teacher Training Program. I release all Its Yoga Satellite teachers and staff from any and all claims of injury and damages caused by my doing, but not limited to, any of the following: misuse of the surroundings, performance of any asana, or any ill use of equipment. I confirm my complete release of all liability for Its Yoga Satellite staff and also including fellow students present. I hereby state that I am in a good health and I understand the intensity of physical participation I have committed to. I confirm that I have no existing mental and physical conditions that would either prevent me from participating or disrupt the delivery of the course. I confirm that I will advise the teachers upon application of any preexisting conditions (both physical and mental) that would affect my performance in the course of study. Any medication that I am taking or have previously taken for such conditions will also be disclosed to the directors of the course, upon application. I fully understand that once I fulfill all the requirements of the Teacher Training Course, I will receive a Certification of Completion. I understand that the yoga teachers and staff reserve the right to cancel my enrollment for any reason and at any time during the course. These reasons may include any inappropriate or unethical behavior which may violate instructions and requirements of the course. I completely understand and agree that there will be no refunds once the course has commenced. However if by any reason I cannot attend the course, and I provide at least 30 days advance notice, my payment may be transfered to any other courses whitin one year after the payment date. If I want to attend another course after the expiration date, I will be required to pay the full amount.Terms and requirements* I have read and accept the above terms and requirements. NameThis field is for validation purposes and should be left unchanged. Δ