Introduction Workshop Registration

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BACKGROUND HEALTH AND YOUR GOALS

Email *

Are you registering for *

Yuan Qigong Introduction Workshop

Autumn Day Retreat May 21

Winter Day Retreat June 18

Spring Day Retreat October 15

Name

Address

Phone

D.O.B

Occupation

Dr & or other Practioner

Present use of Medication/Herbs/Supplements

Any Allergies

Any Present health conditions?

Past History (illnesses, accidents, operations)?

Areas of your life specifically you would like the workshop/Day Retreat to address

What other modalities have you tried and/or are you currently practicing?

Any other information you think is important to know about yourself?

To confirm your place the workshop payment please deposit $60 or Full payment for $79 for intro workshop and $125 for day retreat. Please choose payment type below.

A minimum of 4 participants is needed for the workshops/ Day Retreats to go ahead so your commitment is appreciated.

NZ bank Transfer 123494005895000

Pay Pal nataliejmeijer@gmail.com

Other:

This form remains completely confidential and any detail is filled out voluntarily. If this form is submitted via google docs on a public domain please share information in a way that you feel comfortable alternatively you can print this form and bring to first session . All information is used to increase the effectiveness and safety of the teachers delivery of classes, workshops, retreats or individual sessions you may be attending.

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