Registration Form & Mailing Instructions

August 11-16, 2013 -- Medicine Wheel: An Authentic Indigenous Holistic Healing Tradition

To apply for this intensive, please submit a recent head & shoulder, individual color photo along with your completed registration form and either your deposit or payment-in-full. Please submit all items together at the time of application.

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.

• Do you have previous workshop experience with Rosalyn and Ken (where, when, and what subject)?
• Please indicate your spiritual background. How have you evolved and where are you now? What work have you studied and with whom?
• References - Please share with us how you found our community.

Registration Form

Name_______________________________________________

Address_____________________________________________

City________________________________________________

State/Prov_____________Zip____________________________

Home Phone__________________________________________

Work phone__________________________________________

Email_______________________________________________

Name for ID Tag______________________________________

Emergency Contact Name__________________________________

Emergency Contact Phone #__________________________________

Check # ______ payable to Jean Hollister and/or

MC Visa Disc AMEX
CC#_________________________________ Ex. Date________ Sec. code________

Yes, I will bring a massage table.

Dietary Preference:
All foods (includes chicken or fish option at all dinners)
Vegetarian (including dairy & eggs)
Gluten-free

I will arrive in time for 6 P.M. dinner on Tuesday.

Room Arrangements:
Single (limited #) Double

Roommate Preference____________________________________________
(If you checked double and do not have a roommate preference, one will be provided for you.)