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BYRON BAY VITALITY CHI KUNG RETREATS REGISTRATION FORM

Please advise which Retreat you wish to register for.
Tick appropriate box.

Please fill in all fields marked with a *
	Retreat	Please choose your retreat Qigong FRI 8th October - TUE 12th October 2010 *
	Accomodation	Please choose your accomodation Single Room - $1440 Single Room Early Bird - $1290 Twin Share - $1140 Twin Share Early Bird - $990 *
	First Name	*
	Last Name	*
	Sex	Please specify your sex female male *
	Address Line 1	*
	Address Line 2 (opt.)
	City	*
	State	*
	Postcode	*
	Country	*
	Email	*
	Phone at work
	Phone home / mobile
	Fax
	Date of birth (dd/mm/yyyy)	*
	Occupation
	Is this your first Chi Kung Retreat?	(tick for "yes")
	What do you hope to get from this retreat?
	Do you have any previous Chi Kung training?	(tick for "yes")
	Please describe your previous training shortly
	How many months experience do you have?
	Do you have any medical conditions, disabilities or injuries that we should know about?	(tick for "yes")
	If you answered yes, please specify your medical conditions:
	Where did you find us? (If 'Other' please fill in the ‘Other' section below)	Please choose the reference Magazine Newspaper Internet Friends / word of mouth Other *
	Other
	Anything else you want to let us know
	Do you want to join our mailing list?	(tick for "yes")
	Please acknowledge by checking this box that you have read our conditions	You can read our conditions by clicking here * (tick for "yes")

traditions that have healed and inspired for thousands of years

Byron Living Arts 144 Jonson St.Byron Bay Australia Post: P.O. Box 819 Byron Bay N.S.W. 2481 Tel: 02 66858181 Mobile: 0400 558181