Bali Woman Lead Forum
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#BMJ *OTUJUVUF
Pr ogr ams 20 09
A R evol ut i onar y Appro ach to G l obal L ea der sh i p Ex cel l ence ■ Women Leaders Changing the World (Program runs from January 5-9, 2009)
Women Le a de r s Ch anging the Wor l d ( WL CW )
Price:
Bali, Indonesia • January 4-9, 2009
$7,600 (US) thru June 30 (early bird). $8,500 Beginning July 1
A P rog r am fo r Se n i o r Ex e cu t ive Wo m e n t ha t C rea te s
Includes:
Ex t rao rd ina r y, S us ta in a ble L e ader s h i p Succ e s s
• 5 nights at gorgeous Balinese villa hotel (room nights from 1/4 thru 1/8, single occupancy)
You are invited to join women leaders from around the world who are ready to redesign their leadership and life from the inside out for the sake of changing the world. Be part of an innovative community of global women leaders with vision, passion and a desire for breakthroughs that will enhance and engage your capacity for success and leadership excellence. Explore indigenous wisdom and transformative reciprocal learning that promises to shape your future as a committed global leader.
• 5 breakfasts, 5 lunches, 1 banquet dinner • Airport transfers if arriving/leaving on exact program dates • All program materials
W ha t D oe s t his F ive - da y Pro gra m In cl ude ?
Price does not include:
•
30 hours of learning sessions with world-class experts and a community of senior women leaders from several countries who share similar commitments, concerns and organizational challenges
• Optional tours and excursions
•
Presentations from Balinese indigenous leaders, royalty and cultural experts encouraging you to rethink leadership from a more global perspective
■ Post-Leadership and Coaching Intensive, January 10, 2009
•
Evocative experiences designed to use collective intelligence and wisdom of all participants to expand your capacities as exceptional leaders for the 21st century
•
Materials and tools to maximize learning and ability to transfer to others
•
Time to partner with other participants using an applied learning approach to solve tough organizational challenges
•
Opportunity to collaborate and co-create critical business and leadership strategies that support pivotal business initiatives on a local and global level
• Airfare • Most dinners
Price: $250 Includes: Delicious lunch (Requires extra hotel nights, and arrangements can be made by the Bali Institute)
Space Limited–Register Now! Early enrollment is strongly encouraged to hold a place at this exciting training.
For more information, visit www.baliinstitute.org or call 415-331-7552
So me U nfor get ta bl e To o ls an d Ta ke- awa ys •
Increase organizational value and produce breakthrough results
•
Negotiate win-win solutions with colleagues and clients
•
Build individual and organizational capability to increase performance co nti nued
•
Improve communication skills to exercise influence and execution across boundaries
•
Broaden your understanding of what it means to be a global citizen in an emerging global economy and how to leverage that for your organization
•
Develop practical ways to increase and sustain leadership presence and work-life balance without compromising your ability to make a difference
No t Yo u r U s ua l E xe cu t i ve Pro g ram ! Ins titut e for Wome n’s Leader ship
“
Rayona provided a set of relevant, applicable tools that I can leverage repeatedly to ensure best decisions are made in the fastest, least expensive manner…netting savings across the board ranging from cost-
The Institute for Women’s Leadership is a globally respected leadership institute dedicated to advancing the full partnership of women and men as leaders for sustainable change in organizations and communities. Our approach to leadership effectiveness includes a focus on addressing your specific development needs and providing practical and applicable ways to increase and sustain your leadership presence. We believe that being an extraordinary leader is more about how you impact others and how well you harness the resources within yourself and others to achieve sustainable organizational success. Amazing business results can be achieved through understanding how you leverage individual differences to manage conflict and resolve issues. Our satisfied clients (partial list) who have participated include Adobe, Boeing, Charles Schwab, FedEx, Hewlett-Packard, GAP, Levi Strauss & Co., Oral-B, PWC, SC Johnson, Teva Pharmaceuticals, Visa International, Yahoo and Wells Fargo Bank.
cutting measures to simple things
Bal i Ins ti tut e for Glo bal Renewal
like reducing meeting durations
The Institute for Women’s Leadership is collaborating with the Bali Institute for Global Renewal, a premier world learning and dialogue center that focuses on multicultural leadership training, world dialogues, global activism and other programs that weave Balinese cultural learning and indigenous wisdom practices as a central component of the transformative learning experience. The Bali Institute includes a consortium of international organizations, corporations and thought leaders who are invested in new forms of collaborative leadership training as part of a worldview that promotes a sustainable, humane and culturally-diverse life for all. Facilitators for these programs have included Archbishop Desmond Tutu and two other Nobel peace laureates, the cultural minister of Bhutan, the former president of Indonesia, Apollo 14 Astronaut Edgar Mitchell, members of Balinese royal family and local government, and numerous other dignitaries and world leaders.
down by an average of 50%.
— Gretchen McCoy, SVP, Information Management, Visa Inc.
W ho S h o ul d A tt e nd? Our WLCW program is designed to ensure the highest quality of learning is achieved during your time with us in Bali. Participants are women leaders working within two management levels of the CEO for Fortune 500 companies, government agencies, or organizations achieving critical acclaim at a regional, national or international level. You can expect an environment of generosity, empowerment, relationship and creativity while you partner with peers using an applied learning approach to solving tough business challenges. Scholarship funds are currently being raised to provide an opportunity for a select group of women leaders from developing countries who will benefit from this training. We know that having these women in our training will bring enormous value to enhancing our mutual understanding of global issues and the impact women increasingly have in the emerging global economy. co nt inu ed
#BMJ *OTUJUVUF
For more information or to register, visit www.baliinstitute.org or 415-331-7552
Why Ba l i? The Balinese perspectives on leadership and integral living will provide a fascinating context for expanding our capacity as global leaders in the 21st century. This gorgeous island is one of the most peaceful, beautiful places on earth, and was the recent location for the 2007/08 United Nations Climate Change Conference. Bali’s rich, relationshiporiented culture has much to offer about learning to live harmoniously with one another and our planet. Imagine the excitement and transformative opportunities you’ll have in exploring the emergence of a new kind of sustainable leadership that emanates from indigenous wisdom and grounded in an exchange of cutting-edge leadership practices.
“
Ba li n e se Hi ghl ig h ts I nc lu d e: •
Meetings with local Balinese women village leaders and government officials
•
Evening dialogue and reflection time in small gatherings
•
Special dinner with local Balinese villagers
sharp-edged change. Her under-
•
Private discussion with the royal family in Ubud about indigenous leadership
standing of the relationships
•
Balinese performances unseen by most tourists
among context, behavior, impact,
•
Priceless cross-cultural experiences
•
Lifelong friendships with Balinese
•
Optional visits to schools, orphanages and other innovative NGO programs
Rayona Sharpnack offers a compassionate process for
and engagement is backed by compelling human examples. — Ambassador Swanee Hunt, founding director of the Women and Public Policy Program at the Harvard Kennedy School
A bo u t the Wor kshop L ea de r s Rayona Sharpnack, founder/CEO of Institute for Women’s Leadership. Since 1991, more than 20,000 professionals from Fortune 500 companies have relied on Rayona and her organization, the Institute for Women’s Leadership, to produce breakthrough results both at work and in their personal lives. She has presented her outstanding achievements in advancing women leaders, and building high performance organizations, to prestigious institutions and associations such as: Harvard University, Stanford Business School, UC Berkeley Business School, Mills College, State of the World Forum, the Canadian Federal Government, the Australian Federal Government, Leadership America, and the Professional and Business Women of California. Rayona is also the Chairwoman of Leadership Development at Harvard’s Kennedy School, Women’s Leadership Board. She is the author of Trade Up: 5 Skills for Redesigning Your Leadership & Life from the Inside Out. For more information, visit www.womensleadership.com. Special Balinese guests include Dr. Luh Ketut Suryani, M.D., Ph.D., (invited) retired head of the Psychiatry Department at Udayana University in Bali and a major advocate for women’s issues in Bali and Indonesia. She has her own weekly television program on women and culture. Other invited guests include members of the Ubud Royal Family, local government and civic leaders, and others to be announced soon. Final guest presenters will be listed on www.baliinstitute.com later in 2008.
#BMJ *OTUJUVUF
For more information or to register, visit www.baliinstitute.org or 415-331-7552
Dear Bali Institute Participant: We are delighted that you have chosen to attend one of our programs at the Bali Institute for Global Renewal. Included in this packet are several items to complete your registration process. Please print the following forms, complete them in full, and mail them to the Bali Institute, PO Box 867, Sausalito, CA 94966 or fax them to 415-259-0443: Registration Form Terms & Conditions Form Medical Form Upon receiving your registration documents and payment, we will confirm your registration with an email letter. This letter will have basic information about your Bali Institute program and any additional planning and travel information. Approximately 30 days prior to your program, you will receive a packet in the mail with details about your program, hotel arrangements and other important final information prior to your departure to Bali. Additional helpful information: Travel and Insurance: The Bali Institute does not organize flights or other travel related details. We do recommend Pacific Harbor Travel at (831) 427-5000 for booking your international flights. If you would like to arrive prior to the program or extend your stay and tour Bali, we highly recommend our Bali Institute Travel Manager, Reza Tapilaha at Bali Connection: [email protected] Even though you may be covered by your personal medical insurance, we recommend that you purchase travel insurance, which can cover you in the event of trip cancellation or trip interruption. We recommend CSA Travel Insurance. For more information on travel insurance please contact Pacific Harbor Travel. Special Ubud Medical Assistance Coverage: We have arranged with the Ubud Medical Clinic to provide on-site medical assistance during the your program. The Ubud Medical Clinic provides 24hour care for any number of travel-related ailments or minor medical emergencies. Please read the information below about these services. A portion of your fee helps provide new equipment for the Ubud Medical Clinic and free health care for local Balinese. Of course, at anytime you may contact us with questions at 415-331-7552 or via email at [email protected]. Thank you for registering for this Bali Institute for Global Renewal program. We look forward to spending important time with you in Bali! Warm regards, Marcia Jaffe and the Bali Institute Team
PO Box 867, Sausalito, CA 94966 USA • 415.331.7552 • [email protected] Program Registration Form Participant Information: Name Address City State/Province Country Day phone Mobile phone Gender Roommate preference (if known)
Date: Zip Evening phone Date of Birth
Do you require any special assistance during the gathering? How did you find out about this Bali Institute program? Program Information: Please indicate the dates and title of the workshop you will be attending: Dates: Title: Registration Payment and Process: Payment is due upon registering for the program. Registration fees include accommodations for the duration of the program, airport transfers if arriving/departing on exact program beginning/ending dates, all program activities and events, meals as specified for your program, and basic medical services (A detailed description of these services will is included below). Registration fees DO NOT include airfare, visa costs upon entering Bali, (approximately $25 USD with US Passports and many other countries), items of a personal nature (telephone, laundry, or any incidentals), tourist activities, and any meals not covered by your program fees. Program Fee (Please indicate total) Single Hotel Supplement ($350 for participants who want single occupancy rooms) Total Payment Amount
Please indicate payment method: ___Check
___Paypal
You may complete payment on-line for all registration fees through Paypal. Sign on to PayPal.com and use the "Send Money" feature and submit payment to info@baliinstitute (you do not need to have a PayPal account). For Paypal payments please calculate and add an additional 3% handling fee for your program, and include that with your total payment. If you are mailing your payment, please send a check to the Bali Institute, PO Box 867, Sausalito, CA 94966. Please note that your registration is not complete until we have received your payment, registration, medical and terms and conditions forms.
Terms & Conditions Accommodations and Single Supplements Beautiful Balinese hotels have been carefully selected for your stay in Ubud, Bali. Participants will have a roommate unless a single supplement accommodation has been indicated. Cancellation Policy: Cancellations must be received by the Bali Institute in writing to P.O. Box 867, Sausalito, CA 94966. Refunds will be based on the day written notification is received. Regardless of cause, cancellations result in additional administrative and processing costs, record adjustments, refund checks and other fees. The following penalties will apply on any cancellation handled by the Bali Institute: Minimum non-refundable cancellation fee: $500 31-90 days prior to departure: Lose 50% of registration payment 0-30 days: Lose 100% of registration payment Fees are transferable to other parties or can be credited to a future Bali Institute Program within one year of cancellation. Cancellation Insurance Bali Institute is not responsible if your trip is cancelled for any reason, or for such expenses as airline cancellation fees, visa fees, vaccinations, purchases of clothing and equipment for the conference or other expenses. We strongly urge that you consider taking out insurance, which may protect you in the event of unforeseen cancellations. For medical information on Indonesia contact the Centers for Disease Control at http://www.cdc.gov/travel/. For travel advisories issued by the U.S. government go to http://www.travel.state.gov/. Passports and Visas Indonesia requires that all those seeking entry into the country have a passport that is valid for at least six months beyond your stay in Indonesia. Indonesia allows those holding passports from many countries, including the U.S., to obtain a visa when entering Indonesia for a fee of approximately US$25. In many countries, a visa must be obtained before arriving in Indonesia. It is the responsibility of each traveler to determine his or her need to obtain an Indonesian visa in advance. Responsibilities Bali Institute for Global Renewal and all sponsoring organizations, booking agencies, their staffs and agents act only as agents for the suppliers in regard to travel, whether by airplane, motor coach, motor car, railroad or boat, and assume no liability for injury, damage, loss, accident, delay or irregularity which may be occasioned either by reason of defect or of any company or person engaged in conveying the passenger, or in carrying out the arrangements for the trip. They accept no responsibility for losses or additional expenses due to delays or changes in air or other services, sickness, weather, strike, war, terrorism, quarantine, force majeure or other causes. The right is reserved to substitute accommodations of similar or better quality for those indicated. The issuance and acceptance of voucher or ticket and/or payment and/or written acceptance of these terms and conditions shall be deemed to be consent to the above conditions. In the event of a dispute, it is agreed that litigation will not be initiated by any of the parties but will be settled by negotiation between the parties or by mediation. I accept the above conditions.
Date
Signature
Print Name
Participant Medical Profile Name (please print) __________________________________________ The Gathering in Bali will include some modest physical activity and risk. The sidewalks and walking paths in Bali, for example, include uneven surfaces and steps. The level of participation in any of our workshops or programs is at all times completely up to the individual and any risks must be assumed by each traveler. By giving the Bali Institute for Global Renewal the registration fee and signing below, you are certifying that you do not have any physical or other condition that would create a hazard for yourself or other travelers. It is essential that Bali Institute for Global Renewal be informed in writing below of any medical condition you might have which requires regular treatment or which may be affected by physical activity, heat, or other natural phenomenon, or particular foods. This information is kept confidential and is available only to leadership. 1.) Do you have any limitations to participating in normal group activities (i.e. walking, climbing steps)? ____Yes ____No (If yes, identify and explain) 2.) Do you have any allergies or reactions to medication? ____Yes ____No (If yes, identify and explain:) _____________________________________________________________________________ 3.) What prescribed medications, if any, are you currently taking and for what condition? 4.) Are you currently under the care of a medical professional for any condition that we should be aware of? ____ Yes ____No (If yes, a medical release must be provided by your doctor.) Person who will be available to contact in case of an emergency: Name:________________________________________________________________________ Relationship:___________________________________________________________________ Phone:_________________________________ Email: _________________________________ RELEASE OF LIABILITY I understand that parts of this program may be physically and/or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness or ability to participate in activities. I recognize the inherent risk of injury or disability in activities. I understand that each participant must assume the risk of physical injury that could result from any of the activities. I understand that a participant may choose not to participate in any of the activities. I release Bali Institute for Global Renewal, its staff, supporting and sponsoring organization and their staffs from all liability for any injury or tort, implied or otherwise, to me from participation in the Bali Institute program. Traveler’s Signature________________________________________________________Date:__________
About the Ubud Medical Clinic Services Following are the medical services, benefits and coverage available with your program. Benefits: 1. 2.
4. 5. 6.
Ubud Clinic covers medical expenses for outpatient medical services only. Ubud Clinic includes: • 24-hour emergency assistance • 24-hour medical consultation (clinic or hotel visit or by phone) • 24-hour ambulance service • 24-hour pharmacy • Dentist assistance • Laboratory services • X-ray services Outpatient medical assistance coverage is for the period of your Bali Institute program. Medical assistance will be provided at the Ubud Medical Clinic in Ubud If a person needs further examination or consultation that can’t be provided in the Ubud Clinic, Ubud Clinic will organize the examination at their associate hospital. Ubud Clinic will pay the first 500,000 rupiah (approximately US$50.00) of the total medical expenses of this exam. The rest of the medical expenses will be patient responsibility.
Not covered by this medical plan: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Outpatient and inpatient treatments not provided by Ubud Clinic All types of alternative medicines (acupuncture, herbal medicines, etc.) All types of chronic diseases (i.e. heart failure, kidney failure, liver problems, hypertensions, etc.) Any medical assistance for cosmetic purposes Congenital conditions Birth control, treatment of impotence, sterilization, abortion Hazardous or professional sports Intentionally self-inflicted injury, suicide, abuse of alcohol, drug addiction, or STDs Prosthesis, orthotic devices, or corrective devices
Pr ogr ams 20 09
A R evol ut i onar y Appro ach to G l obal L ea der sh i p Ex cel l ence ■ Women Leaders Changing the World (Program runs from January 5-9, 2009)
Women Le a de r s Ch anging the Wor l d ( WL CW )
Price:
Bali, Indonesia • January 4-9, 2009
$7,600 (US) thru June 30 (early bird). $8,500 Beginning July 1
A P rog r am fo r Se n i o r Ex e cu t ive Wo m e n t ha t C rea te s
Includes:
Ex t rao rd ina r y, S us ta in a ble L e ader s h i p Succ e s s
• 5 nights at gorgeous Balinese villa hotel (room nights from 1/4 thru 1/8, single occupancy)
You are invited to join women leaders from around the world who are ready to redesign their leadership and life from the inside out for the sake of changing the world. Be part of an innovative community of global women leaders with vision, passion and a desire for breakthroughs that will enhance and engage your capacity for success and leadership excellence. Explore indigenous wisdom and transformative reciprocal learning that promises to shape your future as a committed global leader.
• 5 breakfasts, 5 lunches, 1 banquet dinner • Airport transfers if arriving/leaving on exact program dates • All program materials
W ha t D oe s t his F ive - da y Pro gra m In cl ude ?
Price does not include:
•
30 hours of learning sessions with world-class experts and a community of senior women leaders from several countries who share similar commitments, concerns and organizational challenges
• Optional tours and excursions
•
Presentations from Balinese indigenous leaders, royalty and cultural experts encouraging you to rethink leadership from a more global perspective
■ Post-Leadership and Coaching Intensive, January 10, 2009
•
Evocative experiences designed to use collective intelligence and wisdom of all participants to expand your capacities as exceptional leaders for the 21st century
•
Materials and tools to maximize learning and ability to transfer to others
•
Time to partner with other participants using an applied learning approach to solve tough organizational challenges
•
Opportunity to collaborate and co-create critical business and leadership strategies that support pivotal business initiatives on a local and global level
• Airfare • Most dinners
Price: $250 Includes: Delicious lunch (Requires extra hotel nights, and arrangements can be made by the Bali Institute)
Space Limited–Register Now! Early enrollment is strongly encouraged to hold a place at this exciting training.
For more information, visit www.baliinstitute.org or call 415-331-7552
So me U nfor get ta bl e To o ls an d Ta ke- awa ys •
Increase organizational value and produce breakthrough results
•
Negotiate win-win solutions with colleagues and clients
•
Build individual and organizational capability to increase performance co nti nued
•
Improve communication skills to exercise influence and execution across boundaries
•
Broaden your understanding of what it means to be a global citizen in an emerging global economy and how to leverage that for your organization
•
Develop practical ways to increase and sustain leadership presence and work-life balance without compromising your ability to make a difference
No t Yo u r U s ua l E xe cu t i ve Pro g ram ! Ins titut e for Wome n’s Leader ship
“
Rayona provided a set of relevant, applicable tools that I can leverage repeatedly to ensure best decisions are made in the fastest, least expensive manner…netting savings across the board ranging from cost-
The Institute for Women’s Leadership is a globally respected leadership institute dedicated to advancing the full partnership of women and men as leaders for sustainable change in organizations and communities. Our approach to leadership effectiveness includes a focus on addressing your specific development needs and providing practical and applicable ways to increase and sustain your leadership presence. We believe that being an extraordinary leader is more about how you impact others and how well you harness the resources within yourself and others to achieve sustainable organizational success. Amazing business results can be achieved through understanding how you leverage individual differences to manage conflict and resolve issues. Our satisfied clients (partial list) who have participated include Adobe, Boeing, Charles Schwab, FedEx, Hewlett-Packard, GAP, Levi Strauss & Co., Oral-B, PWC, SC Johnson, Teva Pharmaceuticals, Visa International, Yahoo and Wells Fargo Bank.
cutting measures to simple things
Bal i Ins ti tut e for Glo bal Renewal
like reducing meeting durations
The Institute for Women’s Leadership is collaborating with the Bali Institute for Global Renewal, a premier world learning and dialogue center that focuses on multicultural leadership training, world dialogues, global activism and other programs that weave Balinese cultural learning and indigenous wisdom practices as a central component of the transformative learning experience. The Bali Institute includes a consortium of international organizations, corporations and thought leaders who are invested in new forms of collaborative leadership training as part of a worldview that promotes a sustainable, humane and culturally-diverse life for all. Facilitators for these programs have included Archbishop Desmond Tutu and two other Nobel peace laureates, the cultural minister of Bhutan, the former president of Indonesia, Apollo 14 Astronaut Edgar Mitchell, members of Balinese royal family and local government, and numerous other dignitaries and world leaders.
down by an average of 50%.
— Gretchen McCoy, SVP, Information Management, Visa Inc.
W ho S h o ul d A tt e nd? Our WLCW program is designed to ensure the highest quality of learning is achieved during your time with us in Bali. Participants are women leaders working within two management levels of the CEO for Fortune 500 companies, government agencies, or organizations achieving critical acclaim at a regional, national or international level. You can expect an environment of generosity, empowerment, relationship and creativity while you partner with peers using an applied learning approach to solving tough business challenges. Scholarship funds are currently being raised to provide an opportunity for a select group of women leaders from developing countries who will benefit from this training. We know that having these women in our training will bring enormous value to enhancing our mutual understanding of global issues and the impact women increasingly have in the emerging global economy. co nt inu ed
#BMJ *OTUJUVUF
For more information or to register, visit www.baliinstitute.org or 415-331-7552
Why Ba l i? The Balinese perspectives on leadership and integral living will provide a fascinating context for expanding our capacity as global leaders in the 21st century. This gorgeous island is one of the most peaceful, beautiful places on earth, and was the recent location for the 2007/08 United Nations Climate Change Conference. Bali’s rich, relationshiporiented culture has much to offer about learning to live harmoniously with one another and our planet. Imagine the excitement and transformative opportunities you’ll have in exploring the emergence of a new kind of sustainable leadership that emanates from indigenous wisdom and grounded in an exchange of cutting-edge leadership practices.
“
Ba li n e se Hi ghl ig h ts I nc lu d e: •
Meetings with local Balinese women village leaders and government officials
•
Evening dialogue and reflection time in small gatherings
•
Special dinner with local Balinese villagers
sharp-edged change. Her under-
•
Private discussion with the royal family in Ubud about indigenous leadership
standing of the relationships
•
Balinese performances unseen by most tourists
among context, behavior, impact,
•
Priceless cross-cultural experiences
•
Lifelong friendships with Balinese
•
Optional visits to schools, orphanages and other innovative NGO programs
Rayona Sharpnack offers a compassionate process for
and engagement is backed by compelling human examples. — Ambassador Swanee Hunt, founding director of the Women and Public Policy Program at the Harvard Kennedy School
A bo u t the Wor kshop L ea de r s Rayona Sharpnack, founder/CEO of Institute for Women’s Leadership. Since 1991, more than 20,000 professionals from Fortune 500 companies have relied on Rayona and her organization, the Institute for Women’s Leadership, to produce breakthrough results both at work and in their personal lives. She has presented her outstanding achievements in advancing women leaders, and building high performance organizations, to prestigious institutions and associations such as: Harvard University, Stanford Business School, UC Berkeley Business School, Mills College, State of the World Forum, the Canadian Federal Government, the Australian Federal Government, Leadership America, and the Professional and Business Women of California. Rayona is also the Chairwoman of Leadership Development at Harvard’s Kennedy School, Women’s Leadership Board. She is the author of Trade Up: 5 Skills for Redesigning Your Leadership & Life from the Inside Out. For more information, visit www.womensleadership.com. Special Balinese guests include Dr. Luh Ketut Suryani, M.D., Ph.D., (invited) retired head of the Psychiatry Department at Udayana University in Bali and a major advocate for women’s issues in Bali and Indonesia. She has her own weekly television program on women and culture. Other invited guests include members of the Ubud Royal Family, local government and civic leaders, and others to be announced soon. Final guest presenters will be listed on www.baliinstitute.com later in 2008.
#BMJ *OTUJUVUF
For more information or to register, visit www.baliinstitute.org or 415-331-7552
Dear Bali Institute Participant: We are delighted that you have chosen to attend one of our programs at the Bali Institute for Global Renewal. Included in this packet are several items to complete your registration process. Please print the following forms, complete them in full, and mail them to the Bali Institute, PO Box 867, Sausalito, CA 94966 or fax them to 415-259-0443: Registration Form Terms & Conditions Form Medical Form Upon receiving your registration documents and payment, we will confirm your registration with an email letter. This letter will have basic information about your Bali Institute program and any additional planning and travel information. Approximately 30 days prior to your program, you will receive a packet in the mail with details about your program, hotel arrangements and other important final information prior to your departure to Bali. Additional helpful information: Travel and Insurance: The Bali Institute does not organize flights or other travel related details. We do recommend Pacific Harbor Travel at (831) 427-5000 for booking your international flights. If you would like to arrive prior to the program or extend your stay and tour Bali, we highly recommend our Bali Institute Travel Manager, Reza Tapilaha at Bali Connection: [email protected] Even though you may be covered by your personal medical insurance, we recommend that you purchase travel insurance, which can cover you in the event of trip cancellation or trip interruption. We recommend CSA Travel Insurance. For more information on travel insurance please contact Pacific Harbor Travel. Special Ubud Medical Assistance Coverage: We have arranged with the Ubud Medical Clinic to provide on-site medical assistance during the your program. The Ubud Medical Clinic provides 24hour care for any number of travel-related ailments or minor medical emergencies. Please read the information below about these services. A portion of your fee helps provide new equipment for the Ubud Medical Clinic and free health care for local Balinese. Of course, at anytime you may contact us with questions at 415-331-7552 or via email at [email protected]. Thank you for registering for this Bali Institute for Global Renewal program. We look forward to spending important time with you in Bali! Warm regards, Marcia Jaffe and the Bali Institute Team
PO Box 867, Sausalito, CA 94966 USA • 415.331.7552 • [email protected] Program Registration Form Participant Information: Name Address City State/Province Country Day phone Mobile phone Gender Roommate preference (if known)
Date: Zip Evening phone Date of Birth
Do you require any special assistance during the gathering? How did you find out about this Bali Institute program? Program Information: Please indicate the dates and title of the workshop you will be attending: Dates: Title: Registration Payment and Process: Payment is due upon registering for the program. Registration fees include accommodations for the duration of the program, airport transfers if arriving/departing on exact program beginning/ending dates, all program activities and events, meals as specified for your program, and basic medical services (A detailed description of these services will is included below). Registration fees DO NOT include airfare, visa costs upon entering Bali, (approximately $25 USD with US Passports and many other countries), items of a personal nature (telephone, laundry, or any incidentals), tourist activities, and any meals not covered by your program fees. Program Fee (Please indicate total) Single Hotel Supplement ($350 for participants who want single occupancy rooms) Total Payment Amount
Please indicate payment method: ___Check
___Paypal
You may complete payment on-line for all registration fees through Paypal. Sign on to PayPal.com and use the "Send Money" feature and submit payment to info@baliinstitute (you do not need to have a PayPal account). For Paypal payments please calculate and add an additional 3% handling fee for your program, and include that with your total payment. If you are mailing your payment, please send a check to the Bali Institute, PO Box 867, Sausalito, CA 94966. Please note that your registration is not complete until we have received your payment, registration, medical and terms and conditions forms.
Terms & Conditions Accommodations and Single Supplements Beautiful Balinese hotels have been carefully selected for your stay in Ubud, Bali. Participants will have a roommate unless a single supplement accommodation has been indicated. Cancellation Policy: Cancellations must be received by the Bali Institute in writing to P.O. Box 867, Sausalito, CA 94966. Refunds will be based on the day written notification is received. Regardless of cause, cancellations result in additional administrative and processing costs, record adjustments, refund checks and other fees. The following penalties will apply on any cancellation handled by the Bali Institute: Minimum non-refundable cancellation fee: $500 31-90 days prior to departure: Lose 50% of registration payment 0-30 days: Lose 100% of registration payment Fees are transferable to other parties or can be credited to a future Bali Institute Program within one year of cancellation. Cancellation Insurance Bali Institute is not responsible if your trip is cancelled for any reason, or for such expenses as airline cancellation fees, visa fees, vaccinations, purchases of clothing and equipment for the conference or other expenses. We strongly urge that you consider taking out insurance, which may protect you in the event of unforeseen cancellations. For medical information on Indonesia contact the Centers for Disease Control at http://www.cdc.gov/travel/. For travel advisories issued by the U.S. government go to http://www.travel.state.gov/. Passports and Visas Indonesia requires that all those seeking entry into the country have a passport that is valid for at least six months beyond your stay in Indonesia. Indonesia allows those holding passports from many countries, including the U.S., to obtain a visa when entering Indonesia for a fee of approximately US$25. In many countries, a visa must be obtained before arriving in Indonesia. It is the responsibility of each traveler to determine his or her need to obtain an Indonesian visa in advance. Responsibilities Bali Institute for Global Renewal and all sponsoring organizations, booking agencies, their staffs and agents act only as agents for the suppliers in regard to travel, whether by airplane, motor coach, motor car, railroad or boat, and assume no liability for injury, damage, loss, accident, delay or irregularity which may be occasioned either by reason of defect or of any company or person engaged in conveying the passenger, or in carrying out the arrangements for the trip. They accept no responsibility for losses or additional expenses due to delays or changes in air or other services, sickness, weather, strike, war, terrorism, quarantine, force majeure or other causes. The right is reserved to substitute accommodations of similar or better quality for those indicated. The issuance and acceptance of voucher or ticket and/or payment and/or written acceptance of these terms and conditions shall be deemed to be consent to the above conditions. In the event of a dispute, it is agreed that litigation will not be initiated by any of the parties but will be settled by negotiation between the parties or by mediation. I accept the above conditions.
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Participant Medical Profile Name (please print) __________________________________________ The Gathering in Bali will include some modest physical activity and risk. The sidewalks and walking paths in Bali, for example, include uneven surfaces and steps. The level of participation in any of our workshops or programs is at all times completely up to the individual and any risks must be assumed by each traveler. By giving the Bali Institute for Global Renewal the registration fee and signing below, you are certifying that you do not have any physical or other condition that would create a hazard for yourself or other travelers. It is essential that Bali Institute for Global Renewal be informed in writing below of any medical condition you might have which requires regular treatment or which may be affected by physical activity, heat, or other natural phenomenon, or particular foods. This information is kept confidential and is available only to leadership. 1.) Do you have any limitations to participating in normal group activities (i.e. walking, climbing steps)? ____Yes ____No (If yes, identify and explain) 2.) Do you have any allergies or reactions to medication? ____Yes ____No (If yes, identify and explain:) _____________________________________________________________________________ 3.) What prescribed medications, if any, are you currently taking and for what condition? 4.) Are you currently under the care of a medical professional for any condition that we should be aware of? ____ Yes ____No (If yes, a medical release must be provided by your doctor.) Person who will be available to contact in case of an emergency: Name:________________________________________________________________________ Relationship:___________________________________________________________________ Phone:_________________________________ Email: _________________________________ RELEASE OF LIABILITY I understand that parts of this program may be physically and/or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness or ability to participate in activities. I recognize the inherent risk of injury or disability in activities. I understand that each participant must assume the risk of physical injury that could result from any of the activities. I understand that a participant may choose not to participate in any of the activities. I release Bali Institute for Global Renewal, its staff, supporting and sponsoring organization and their staffs from all liability for any injury or tort, implied or otherwise, to me from participation in the Bali Institute program. Traveler’s Signature________________________________________________________Date:__________
About the Ubud Medical Clinic Services Following are the medical services, benefits and coverage available with your program. Benefits: 1. 2.
4. 5. 6.
Ubud Clinic covers medical expenses for outpatient medical services only. Ubud Clinic includes: • 24-hour emergency assistance • 24-hour medical consultation (clinic or hotel visit or by phone) • 24-hour ambulance service • 24-hour pharmacy • Dentist assistance • Laboratory services • X-ray services Outpatient medical assistance coverage is for the period of your Bali Institute program. Medical assistance will be provided at the Ubud Medical Clinic in Ubud If a person needs further examination or consultation that can’t be provided in the Ubud Clinic, Ubud Clinic will organize the examination at their associate hospital. Ubud Clinic will pay the first 500,000 rupiah (approximately US$50.00) of the total medical expenses of this exam. The rest of the medical expenses will be patient responsibility.
Not covered by this medical plan: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Outpatient and inpatient treatments not provided by Ubud Clinic All types of alternative medicines (acupuncture, herbal medicines, etc.) All types of chronic diseases (i.e. heart failure, kidney failure, liver problems, hypertensions, etc.) Any medical assistance for cosmetic purposes Congenital conditions Birth control, treatment of impotence, sterilization, abortion Hazardous or professional sports Intentionally self-inflicted injury, suicide, abuse of alcohol, drug addiction, or STDs Prosthesis, orthotic devices, or corrective devices
