Imagine Living Well LLC Transpirational Adventures Registration Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Waiver & Liability
Release and Waiver Confirmation
*
Yes, I confirm I have read and understand and agree to the Imagine Living Well Release and Waiver on behalf of myself and any minor children or others over whom I have guardianship listed below.
Type or sign your name
Please list any minor children or adults for whom you have guardianship who will be accompanying you on this Transpirtational Adventure and on whose behalf you are acknowledging and agreeing to the Imagine Living Well Release and Waiver (if applicable).
First Name, Last Name, Age, Relationship
Select Your Adventure!
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( X )
Polar Express on Chamele
$
10.00
Quantity
Peace Train
$
30.00
Quantity
I Am Well
$
30.00
Quantity
Body/Mind/Spirit
$
30.00
Quantity
True Colors
$
30.00
Quantity
Girls Just Want To Have Fun
$
85.00
Quantity
1
2
3
4
5
6
7
8
9
10
Customized Adventure
$
30.00
Quantity
Guest
$
Free
Submit
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