The Wiraqocha Foundation for the preservation of the indigenous spiritual wisdom of the Inkas

Initiation trips to Peru: online registration
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Name: (as on passport)

Mailing Address
Street:

City:

State:

Zip Code:

Ofc. Phone:

Res. Phone:

Fax Number:

Email Address:

Date of Birth: (m/d/y)

Passport Number:

I want to share a room with

I am willing to share a room with a male female

I prefer a single room (single suplement required add 20% of trip cost)

Emergency contact name and number

T-shirt size (select one) s m l xl xxl

Vegetarian Yes No (select one)

Trip # (see list below) Deposit USD $

Full Amount USD $

Trip #Nov07: November 8-20, 2007, Hatun Karpay led by Elizabeth Jenkins.

Check dates carefully; failure to pay on time may disqualify your trip participation.
Full payment due 65 days prior to travel date.
All participants required to carry full Emergency Medical Insurance.

Payment Method:

Check enclosed (payable to Wiraqocha Foundation)
NOTE: Check paying customers in addition to submitting this form electronically, please print this form out and mail with check to:
Wiraqocha Foundation
PO Box 500
Na’alehu Hawaii 96772
(808) 929-8785
(808) 929-7370

To Submit this electronic form, please click here: