Registration Form – Health Practitioner Retreats

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:
Area of expertise:
List dietary restrictions, if any:
I heard about this cancer retreat via:


I choose the following option (please call us at 808-889-9893 for room availability):

I will:
Pay the full amount of $140 to Kokolulu Cancer Retreats. Pay the full amount of $140 plus $85 for overnight accommodations to Kokolulu Cancer Retreats. I agree: * I have read and agreed upon the terms and conditions