Application_form

APPLICATION FORM
FOR HEALTH PACKAGE STAYS AT “WIELICZKA” SALT MINE
UNDERGROUND REHABILITATION AND TREATMENT CENTRE
(to be filled out and posted to the Centre)
I BOOK HEALTH PACKAGE STAY – period: . (periods as set in the health package stays offer)*
□ The Salt Mill Guest Rooms
I book: □ single room; □ double room; □ triple room; □ FB (4 meals); □ HB (2 meals); □ BB (breakfast)
I book the transport from: □ railway and bus station in Cracow or □ from airport Cracow Balice
□ Grand Sal Hotel 4*
I book: □ single room; □ double room; □ triple room; □ FB (4 meals); □ HB (2 meals); □ BB (breakfast)
I book the transport from: □ railway and bus station in Cracow or □ from airport Cracow Balice
(please sign preferred hotel and number of meals) Health package stay programme includes:
• Consultations with the physician and the underground safety training organized on the first day of the visit,
• Five 6.5-hour health visits underground supervised by medical personnel – physician, nurse, physiotherapists and music • One over-night stay in the mine – sleeping in subterranotherapy conditions, • 6 nights at one of the selected hotels (Grand Sal Hotel 4* www.grandsal.pl; The Salt Mill Guest Rooms • FB (Full Board, 4 meals: including also brunch or afternoon snack taken into the mine) or HB (Half Board, 2 meals: breakfast and late dinner) or BB (breakfast) • climate therapy – rehabilitation and treatment walk in the historic part of the Mine with health prevention education and elements of respiratory exercises in Polish (there is a possibility to have a foreign language tour - extra fee) • for individual choice - one of the following packages: Relax Package, Beauty Package, Wellness Package, • 3 x 2 hours at the swimming-pool ”Solne Miasto” in Wieliczka • transfer to-and-from the Main Railway Station in Krakow or the Krakow-Balice airport. RELAX PACKAGE □
BEAUTY PACKAGE □
WELLNESS PACKAGE □
• „The Touch of Silk” – hydrating • „The Feast for the Skin” – facial ** the kind of procedure will be chosen by the cosmetologist, accordingly: a procedure for dry and sensitive skin, procedure for oily and
combination skin, procedure for mature skin.
*We can only offer a limited number of places during each period of health vacation. Selection is based on the “first come – first served”
basis. Should we not be able to accommodate you during the desired period, we will offer you another period of health vacations.
Non-profit Health Care Institution The Wieliczka Salt Mine
Underground Rehabilitation and Treatment Centre fax: +48 /12 / 288-27-73
Park Kingi 1 bud. I
32-020 Wieliczka www.sanatorium.kopalnia.pl I. Requirements:
- children from 4 years old,
- physical motor ability,
- chest’s X-ray test (valid for 2 years)
- making a deposit payment subsequent to receiving a Confirmation Note stating that the patient has been accepted
for health vacations.
II. Payment conditions
I hereby undertake to make a deposit payment equal to 45% of the total sum for health package stay, within a period of 30 days
prior to the beginning of my period of stay on receiving a Confirmation Note for health vacations at “Wieliczka” Salt Mine.
Should I receive the Confirmation Note within less than 30 days before the beginning of the treatment period, I undertake to
transfer the deposit of 45 % of the total sum to the Sanatorium account within a period of 3 days from the day of receipt of the
Confirmation Note. I shall send a copy of the payment transfer document by fax. (The account number and the fax number shall
be indicated in the Confirmation Note). I shall pay the remaining part of the sum on the day of arrival at the “Wieliczka” Salt
Mine.
III. Cancellation
Should the visiting person cancel his/her application for treatment after having paid the deposit payment by transfer, the
Organising Party shall deduct:
- 100 PLN, in cases when the application is cancelled 30 or more days prior to the beginning of the health vacations.
- 50% of the transferred amount, when the application is cancelled within 29-15 days prior to the beginning of the health
vacations
- 80% of the transferred amount, when the application is cancelled within less than 14 days prior to the beginning of the stay
- 100 % of the transferred amount should the applicant(s) not arrive for the stay.
Once the treatment period has started the patient does not get his money back if he cancels his stay. If a patient has not been
classified by a specialist to undergo the treatment, his deposit is paid back unless some accommodation costs have been paid.
IV. Contraindications:
Absolute contraindications: an active malignancy or a history of a malignancy within the last 5 years; immunosuppressive
treatment: cytostatic agents, cyclosporine, radiotherapy, high doses of steroids – regardless of the cause; serious diseases of the
musculoskeletal system, precluding independent mobility; severe respiratory or circulatory insufficiency, limiting physical
activity to a minimum; active infectious diseases, acute and chronic (a positive carrier status is not a contraindication); acute
infectious diseases with fever.
Relative contraindications (treatment at the patient’s own risk): rheumatic and degenerative diseases of the osteoarticular
system; coronary heart disease – unstable angina or rhythm disorders with a risk of syncope; uncontrolled arterial hypertension;
uncontrolled diabetes mellitus; mental diseases, especially depressive disorders and claustrophobia;
V. Additional information
- The temperature in the salt chambers of the Wieliczka mine is 9° - 12°C, so it is advisable to wear warm sport clothing.
- It is not allowed to smoke and use open fire underground and all participants must follow the rules concerning safety, anti-fire
protection and health, and advices of medical staff.
I hereby acknowledge that I have read the application form and agree to comply with the presented conditions, and I grant
permission for processing my personal data included in this Application Form only for the purposes of Wieliczka Salt Mine
Underground Rehabilitation and Treatment Centre.
. .
( Place and date ) (Applicant’s legible signature)
Non-profit Health Care Institution The Wieliczka Salt Mine
Underground Rehabilitation and Treatment Centre fax: +48 /12 / 288-27-73
Park Kingi 1 bud. I
32-020 Wieliczka www.sanatorium.kopalnia.pl

Source: http://www.kopalnia.pl/files/uzdrowisko/druki/7DNIOWE_POBYTY_ZDROWOTNE/APPLICATION_FORM.pdf