Registration

To secure your place, please fill in the online registration form, registration closes 25th February 2017. $500 deposit is required.

Participant Details

First Name (required)

Last Name (required)

Birth Date (required)

Gender (required)

Native Language (required)

Your Email (required)

Confirm Email (required)

Street Address (required)

Suburb (required)

Postal Code (required)

State (required)

Country (required)

Phone (home)

Phone (mobile)

Phone (work)

Referral Source (required)

Retreat Details

Have you done a Half Fasting Retreat with Chuya before? (required)

If yes, please specify year(s) attended

Please note that a deposit of $500 is required to confirm this booking (deposit is not refundable from October 10th 2014). Payment is to be made by PayPal. Payment of the full course fee is due by 24th of October, 2014.

Occupation

Any special health or dietary considerations (required)
If none please enter "None".

Please describe your normal diet (required)
Please provide details of what your diet is like in general (including meat, poultry, seafood, dairy, sweets, vegetables, fruits etc.). The more information you provide will give us a better insight into your body's condition.

Medical conditions (required)
Please provide brief details of any current and past medical conditions you have (include allergies, medications, psychiatric treatment, nervous disorder etc.). Please advise if you are pregnant. If none please enter "None".

Impediment to Activities (required)
Please provide information about any injuries or conditions which may impair your ability to participate in physical activities. If none please enter "None".

Family history of major diseases (required)
Please provide information about any past diseases or conditions which have affected members of your family (please state your relationship to that person). If none please enter "None".

Outline any particular diet you are following at present (required)
If none please enter "None".

What is your overall view on health? And how is your emotional/mental health? (required)
If none please enter "None".

What are you hoping to achieve in the Detox Half Fasting Retreat? (required)
If none please enter "None".

Emergency Contact Name

Emergency Contact Phone

Want to register additional participants? Please finish this registration page and complete a separate registration for each participant.

Before continuing to the next page, please ensure all information has been entered correctly.

Agreement * By checking this box I hereby confirm that the information I have provided in this application is true and correct. I have read and accept the terms and conditions.

 I agree to terms & conditions

Please have your PayPal login details ready before proceeding from this page, as the page after this will automatically time out after a few minutes of inactivity.

Once you are ready, click continue to confirm and organise payment on the next page.

 

 

8 comments for “Registration

  1. phillip.s.davies@hotmail.com
    May 18, 2014 at 12:59 pm

    For some reason until tonight I could not locate the registration form.
    Anita’s registration will follow in the next day or so.
    Anita has advised me that we will be able to have a double room as in the previous 2 retreats at Govinda Valley – kindly advise if this is not so.
    Love,
    Phil

    • Kayu Hashimoto
      May 21, 2014 at 5:49 am

      Hi Phil, thanks for your comment. I have received your registration and sent my reply to your email address. Hope it has reached you! Looking forward to welcoming both of you again this year :-)

      • Phillip Davies
        July 4, 2014 at 12:15 pm

        Hi Kayu – here finally is Anita’s registration. She has been busy getting ready for a 7 week visit back to Canada. She leaves tomorrow.
        Love,
        Phil

        • Kayu Hashimoto
          July 14, 2014 at 7:56 pm

          Hi Phil, I have noticed that Anita’s registration is yet to come through for some reason. I hope it’s not an issue on my end.. I hope Anita is having a relaxing summer in Canada – it must be gorgeous there now!

  2. Judith
    July 14, 2014 at 9:16 pm

    I would like to be in a double room if possible. I have read that they are booked out, but I am hoping that someone will drop out.. . . wouldn’t I be lucky!

    • Kayu Hashimoto
      July 15, 2014 at 11:29 am

      Hi Judith, I have just sent you an email. Should you have any questions please let me know. Thanks, Kayu

  3. Judith Helen Shaw
    July 14, 2014 at 9:31 pm

    Please advise about payment.

    I have paid the deposit of $500.

    I want to know about refundability – until when is that amount able to be refunded?

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