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| One of the steps of registration is filling out this form. You may print it , fill it out and mail it to us or you may copy the form by selecting the text below with your mouse, and pasting it into the email provided by clicking Here. |
| Registration and Contact for
Kokolulu Cancer Retreats Center SURVIVING CANCER GROUP RETREAT - *One week for only $2950 (7 days, 6 nites) For only an additional $650/wk, a loved one in your family can come and be a part of your support team *You may extend your stay by 1 or more weeks 2008 Schedule Group Retreats (personal retreats - see information below) January 11 -16
March 11 - 16 May 5 - 10 September 29 - October 4 December 1 - 6 SURVIVNG CANCER PERSONAL RETREAT - For only $2950 per week (7 days, 6 nites) For only an additional $650/wk, a loved one in your family can come and be a part of your support team 2008 Schedule - Personal Retreats At Any Time (depending on space availability) To reach an admissions counselor, please contact us: In Hawaii, United States of America: 1-808-889-9893 or lew@kokolulu.com www.kokolulu.com I am registering for (please check appropriate line): _ Individual Personal Retreat, dates I would like are:____________________ Group Retreat Dates in 2008: _ January 11 - 15 _ March 11 - 15 _ May 5 - 9 _ July 21 - July 25 _ September 29 - October 3 _ December 1 - 5 Name: _______________________________________________________ Address: _____________________________________________________ City, State, Zip _________________________________________________ Home Phone: ________________ Business Phone: ___________________ Cell Phone: ________________ Email: ___________________ Emergency Contact Person:_________________________Phone:_________ Referred by:___________________________________________ Special Diet Needs: check below and explain _ Low sodium _ Allergy to food, etc __________________________________________ _ Difficulty eating _____________________________________________ _ Chewing or swallowing _ Vegetarian _ Lactose intolerant Massage: Physician's Signature Sheet (see link) Other ___________________________________________________________ As a participant in the retreat, I will not break the confidentiality statement below. I know my own physical abilities and I promise not to over extend my ability. I understand that information I share with others at the retreat is confidential. I understand that I cannot reveal any information shared by other retreat participants. Signed: ___________________________________ Date: _______________ Participants must be: Over the age of 18 years; Medically stable to participate in our program The Admission Process A confidential pre-admission telephone assessment is conducted with all individuals seeking admission to Kokolulu's Cancer Retreats Center by our registered nurse, Karin Whitney Cooke. The purpose of this assessment is to gain an understanding of your specific situation with respect to your history, physical and emotional health. Admission can often take place within 1-2 days following the assessment. Following the confirmation of your admission, we will ask you to provide a security deposit to reserve your space for the agreed upon date. Your complete payment must be received prior to your arrival. Cost - The price for a *One week group retreat is only $2950 (7 days, 6 nites) $650/wk for a family support member joining you *You may extend your stay by 1 or more weeks The cost includes: • Pick up and return to the Kailua-Kona airport • Room (six nights) and three nutritiously healthy meals a day • Individual meetings with our on staff nurse and therapist • Daily individual/group counseling sessions • Holistic alternative therapies, such as qigong, massage, reiki, acupuncture, Sand and salt water detox (at the beach), and other healing energy techniques • Travel to sacred healing Hawaiian sites on the island • Use of our onsite Chinese temple and Dragon water gardens • A rural farm environment with clean air and beautiful views of the ocean and mountains of Hawaii. "If you wish to pay by credit card or paypal account, please click on the "Buy Now" button" Cost - of the one week individual retreat is $2950 (7 days, 6 nites) For only an additional $650/wk, a family support member can join you The cost includes: • Pick up and return to the Kailua-Kona airport • Room and three nutritiously healthy meals a day • Individual meetings with our on staff nurse and therapist • Daily individual/group counseling sessions • Holistic alternative therapies, such as qigong, massage, reiki, acupuncture, Sand and salt water detox (at the beach), and other healing energy techniques • Travel to sacred healing Hawaiian sites on the island • Use of our onsite Chinese temple and Dragon water gardens • A rural farm environment with clean air and beautiful views of the ocean and mountains of Hawaii. please click on the "KoKoLuLu" button" Scholarship We have limited scholarships for individuals who cannot afford the full fee. Kokolulu's Cancer Retreats Program does not accept insurances and therefore all payments must be made by one of the following means: Cash, Unites States Postal Money Order, certified bank draft, Wire transfer. We look forward to being of help to you as you walk the path of healing recovery here at the Kokolulu Cancer Retreat Center. Aloha and Peace Lew and Karin Whitney Kokolulu Cancer Retreats Program P.O. Box 340 Hawi, Hawaii 96719 Phone: (808) 889-9893 Web site: www.cancer-retreats.org www.kokolulu.com |
