Hawaii Group Retreats Registration

Space is limited!

Please fill in the following information and send it to us using the 'submit' button. Fill in one registration form for each person please.

* = required field


* First Name:
* Surname:
Gender (M/F):
Date of Birth:
Full Address:
City:
Postcode:
Country:
* Telephone number:
* Email Address:
I come to the retreat with:
Level of cancer experience:
List dietary restrictions, if any:
I heard about this cancer retreat via:
Please choose a retreat date Jan. 24-28, 2010 Mar. 7-11, 2010 Apr. 25-29, 2010 June, 2010 Aug. 22-26, 2010 September, 2010 Oct. 17-21, 2010 Nov. 7-11, 2010 Dec. 5-9 , 2010


Free Group Cancer Retreat, (5 days/4 nights) all inclusive package
I will:
Extend my stay (beyond the free retreat 4 nights/5 days) @ $450 a day. Please call 808.889.9893 for availability, before you pay for the extra days. In the PayPal system, please specify the number of days x $450 a day. The full amount of payment is required in advance to Kokolulu Farm and Cancer Retreats Inc. to secure your stay. I agree: To send Kokolulu Farm and Cancer Retreats Inc. a $350 deposit (required) to register for a group retreat (please pay this fee only by a personal check made out to Kokolulu Farm and Cancer Retreats Inc. and send to P.O Box 340 Hawi, Hawaii 96719). This fee is a required deposit to secure your place in the free group retreat (we require all participants to make this deposit). This check WILL NOT BE PROCESSED unless you cancel less than 30 days in advance of a retreat where you have a confirmed space on the roster (you would receive your deposit back if you have a medical or family emergency that prevents attendance).