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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.

1. A recent head & shoulder, individual color photo.
2. For new students, your typed thoughtful responses to the questions below on a separate paper, limiting your answers to 1-2 paragraphs per question.

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.

• 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#__________________________________

$1025 Regular Fee
Kama’aina Rate, $50 off.

Note: fees will not be charged to CC or checks not cashed until start of workshop so it pays to register early!

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 (808) 327-5626
Email rama@physicianretreats.com

Questions? Please feel free to phone Rama Thiruvengadam, MD at (808) 443-8949, or email rama@physicianretreats.com