First Name *    Last Name *   Middle Initial

Street Address*

My City*   My State/Province*

My Zip/Postal Code *     My Country*

My Telephone*   My Fax*   My Email*

My Date of Birth* birth day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 birth month January February March April May June July August September October November December    Gender* Male      Female

* Choose one of the following trip dates: choose trip Journey To Shangri-La May 19-June 3, 2013

Do you have any experience in Qigong, Tai Chi (Taiji), meditation, etc?  yes       no

if yes please explain

*List any physical limitations that would keep you from participating with the group. yes       no
if yes please explain

* Do you have any special food needs we should know about (allergies, diets, restrictions) yes       no
if yes please explain

* Accommodations       (private room additional $755.00)

choose option private room where available Shared room

Name of preferred room mate (if applicable)


* Payment Options
choose payment typeMaster card Visa Discover American Express check   Enter your credit card number  - --

*Enter the expiration date of your credit card  JanFebMarAprilMayJuneJulyAugSeptOctNovDec 2012 2013 2014 2015 2016     *CV#


Chooseyes  I agree that I will be billed $800 as my trip deposit charged on the credit card I have entered above and that I have read and
 understand the cancellation policy below.


CANCELLATION & REFUND POLICY: If the tour participant cancels the program, refunds will be made according to the following schedule of cancellation fees:
1. If cancellation notice is received before midnight January 1, 2014 - $300 administration fee plus any out of pocket expenses incurred for trip member’s portion of the trip including airline tickets.
2. If cancellation notice is received after midnight January 1 to midnight February 1, 2014 - $500. administration fee plus any out of pocket expenses incurred for trip member’s portion of the trip including airline tickets.
3. If cancellation notice is received after midnight February 1, to midnight March 1, 2014 - $800. administration fee plus any out of pocket expenses incurred for trip member’s portion of the trip including airline tickets.
4. If cancellation notice is received after midnight March 1, 2014 and up to departure date of trip, - $1,000. administration fee plus any out of pocket expenses incurred for trip member’s portion of the trip including airline tickets.
5. There are no refunds for termination of travel AFTER trip begins. Even if a member must involuntarily cancel for physical health reasons AFTER the trip within China has begun, and does not use a portion of their already pre-paid services, no refunds will be made. No refunds are made for unused excursions and special program activities.