Back
To apply for this intensive, submit the following items along with your completed registration form and payment-in-full. Please submit all items together at the time of application.
We are sorry that incomplete applications cannot be accepted.
New Students: If this is your first intensive with Rosalyn and Ken, please provide the following additional typed information with your registration, limiting your answers to 1-2 paragraphs per question.
Name_______________________________________________
Address_____________________________________________
City________________________________________________
State/Prov_____________Zip____________________________
Home Phone__________________________________________
Work phone__________________________________________
Email_______________________________________________
Name for ID Tag______________________________________
Emergency Contact Name__________________________________
Emergency Contact Phone#__________________________________
Please check ALL that apply:
$1097 Regular Tuition Fee $125 Commuter Fee (if not staying at workshop hotel), OR I'm staying at workshop hotel. Kama’aina Courtesy (I'm a Hawaiian resident, please waive the commuter fee)
Payment Information: Check # ______ payable to HLCC and/or
MC Visa Disc AMEX CC#_________________________________Ex. Date________
Dietary Preference: All foods Vegetarian, including dairy & eggs (Sorry, we cannot accommodate special diets ).
Sunday Arrival: I will arrive in time for the Welcome Luau Dinner on Sunday at 5:30PM.
Room Share: Would you like to share a room? Yes No If yes, please give your gender and age. Gender: M F Age:_____
Rental Car Share: Would you like to share a rental car? Yes No If yes, please provide arrival and departure information.
To register for this workshop please fill out the form above and send (mail, fax or email) it along with your payment AND color photo to:
Rama Thiruvengadam, MD PO Box 390988 Keauhou, HI 96739 OR, Fax to (866) 873-7376Email rama@physicianretreats.com
Questions? Please feel free to phone Rama Thiruvengadam, MD at (808) 443-8949, or email rama@physicianretreats.com