Mystical Abode

Questionnaire for 2020 China Trip

Please complete, then print, then mail with a signed copy of the terms and conditions,
and a photocopy of your passport photo page & China Visa page (if you already have a China visa) to:

Mystical Abode
4672 Eleanor Drive
Carpinteria, CA 93013-1724

Name: Phone:

Passport number: Country of issue:

Exact name as it appears on your passport:

Address (number & street):
City: State: Zip:

E-mail address:     Date of Birth:

Sex: Female   Male   Other       Have you purchased travel insurance? Yes No

Do you have food preferrences? Vegetarian Fish & Poultry Meat No Preference

Do you smoke? Yes   No     Are you taking any medication? No Yes (describe):

Do you have allergies or known medical conditions? No Yes (describe):

I have a roommate.   Name:
I do not have a roommate at this time, please pick one for me.
I prefer a single supplement ($1,000 upon availability).

How did you hear about this trip?
Mystical Abode or Jessica Kolbe.
Advertisement (please name the source of the ad that you saw:
Other (describe)

Do you have prior qigong/Tai Chi experience? Please describe

Do you have other interests/hobbies that you would like to explore while in China e.g., birdwatching? No Yes (describe):

Please provide two emergency contacts:
Name: Phone:

Name: Phone: