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Copyright © 2004, All Rights
Reserved, FeeltheQi.com, Dr. Roger Jahnke
Institute of Integral Tai Chi and Qigong
243 Pebble Beach, Goleta, CA 93117
805-685-4670,
Fax 805-685-4710
info@feeltheqi.com
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Qi Empowerment Summer Retreat,
August 5-7, 2005
with Roger Jahnke, OMD and Matthew Sweigart, CI
Registration Application
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Please
print this form and mail along with your check, money order, or
Visa orMastercard account and expiration made payable to
Zen Gate
P.O. Box 1585
Kings Beach CA 96143
| Name |
| Home
Address |
| City/State/Zip
Code |
| Daytime
Telephone |
| Evening
Telephone |
| E-mail
address |
| Emergency
contact name |
| Emergency
contact phone |
| How
did you hear about this event? FeeltheQi.com
website? Other? |
| Is
there a person or persons with whom you would like to share
a room?
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|
What
are your dierary preferences?
a.
Are you a vegetarian?
b.
Do you eat chicken?
c.
Do you eat fish?
d.
Do you drink coffee or decaffeinated coffee?
e.
Do you eat desserts?
f.
Do you have food allergies or sensitivities?
g.
Other considerations?
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Have
you completed any instruction and personal practice in one
or more forms of Qigong and/or Tai Chi?
If
YES, please list the forms and number of years have studied,
practiced or taught each form.
|
| Do
you have any limiting physical conditions, which might affect
your full participation in this program? If YES, please list
physical conditions or considerations, which may limit your
participation. List any prescription medications.
|
| Are
you comfortable with physical movement for extended periods
of time and training? YES ____ NO ____ If you are currently
receiving medical treatment, please discuss your participation
with your physician and follow his or her recommendations. |
| Are
you comfortable participating in a group training environment,
which requires giving and receiving feedback? YES ____ NO ____ |
| List
any other credentials you may have in nursing, health care provider,
bodywork, teaching, acupuncture, counseling, occupational therapy,
physical therapy, or social services. |
| Please
tell us your primary reason for enrolling in the Institute of
Integral Qigong and Tai Chi's certification trainings |
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By signing
I certify that I have read the refund policy and agree to
its provisions.
SIGNATURE:
_______________________________________________________________________________
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FEES
Participant Fees include
per person rate covers Friday - Sunday, 2 nights lodging,
6 meals, workshop tuition and all activities. Deduct $100
from fee when paid in full by July 1, 2005.
Adult or Child Guest Fees include
per person rate covers Friday - Sunday, 2 nights lodging,
6 meals. Deduct $50 from Adult Guest fees and $30 from Child
fees when paid in full by July 1, 2005.
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Accommodations
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Adult Participant
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Adult Guest
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Child
|
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Camping
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$575
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$395
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$125
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Shared Indoor
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$645
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$445
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$145
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Private Indoor
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$725
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$525
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$175
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Early Bird
Savings When Paid in Full by July 1, 2005
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- $100
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-$50
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- $30
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Pre- and Post-Retreat per person
per night fee
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Extra Night
Fee
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Adult Participant
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Adult Guest
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Child
|
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Camping
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$65
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$65
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$35
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Shared Indoor
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$75
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$75
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$40
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Private Indoor
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$85
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$85
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$45
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Directions and detailed itinerary
will be mailed upon receipt of registration.
Amount
Enclosed: ____________________________
Visa, MasterCard, Checks and Money Orders accepted.
Cancellation Policy
A 50% deposit will hold your space at the retreat. Payment
must be received in full to receive the early registration
discount. Withdrawal with notification more than 21 days prior
to the retreat will receive a refund less a $90 withdrawal
fee per person. Less than 21 days notice, no refund, but you
may send someone in your place.
For Questions or registration by phone contact, Zen Gate
Living Arts, Phone 530-546-7200, Email zengate@sbcglobal.net
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"When
you cultivate balance and harmony within yourself, or in the
world -- that is Tai Chi. When you work and play with the
essence
and energy of life, nature and the universe for healing, clarity
and
inner peace -- that is Qigong."
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