:: Structure ::

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:


I choose the following option (please contact Waka Maya Resort and Spa for room availability):

I will:
Pay a non-refundable deposit of 50% which is required at the time of registration. The remaining 50% payment is due 2 weeks before the time of your arrival at Kokolulu. Pay the full amount to Kokolulu Cancer Retreats (asap) I agree: * I have read and agreed upon the terms and conditions