Tai Chi and Qigong Registration for Training Community Facilitator & Classes

Roger Jahnke OMD Institute of Integral Qigong and Tai Chi (IIQTC)
130 S Patterson Ave #1447
Santa Barbara, CA 93116
Phone 805-617-3390
Email info@feeltheqi.com

Legal Stuff

Disclaimer

Community Facilitator Training Registration

October 22-29, 2004 Asheville, NC

YMCA Blue Ridge Assembly

Please call Rhonda Richey at 805-685-4670 or 805-560-7277; e-mail info@feeltheqi.com; or use the form below. A $500 deposit will reserve your place until October 1, at which time full payment is due.

For secure online registration through Acteva.com, click button

If paying by check or money order, please print this form and mail along with your check or money order, made payable to:

Institute of Integral Qigong and Tai Chi
243 Pebble Beach Dr.
Goleta, CA 93117.

Name

Home Address

City/State/Zip Code

Daytime Telephone

Evening Telephone

E-mail address

Emergency contact name

Emergency contact phone

Is there a person or persons with whom you would like to share a room?

What are your dierary preferences?

a. Are you a vegetarian?

b. Do you eat chicken?

c. Do you eat fish?

d. Do you drink coffee or decaffeinated coffee?

e. Do you eat desserts?

f. Do you have food allergies or sensitivities?

g. Other considerations?

Have you completed any instruction and personal practice in one or more forms of Qigong and/or Tai Chi?

If YES, please list the forms and number of years have studied, practiced or taught each form.

Do you have any limiting physical conditions, which might affect your full participation in this program? If YES, please list physical conditions or considerations, which may limit your participation. List any prescription medications.

Are you comfortable with physical movement for extended periods of time and training? YES ____ NO ____ If you are currently receiving medical treatment, have you discussed your participation with your physician?

Are you comfortable participating in a group training environment, which requires giving and receiving feedback? YES ____ NO ____

List any other credentials you may have in nursing, health care provider, bodywork, teaching, acupuncture, counseling, occupational therapy, physical therapy, or social services.

Please tell us your primary reason for enrolling in the Institute of Integral Qigong and Tai Chi's certification trainings

Tuition, Lodging, and Meal Plan Fees

A = Bunk Accommodations, 21 meals, tuition and on site training materials.

B = Double with Shared Bath, 21 meals, tuition and on site training materials

C = Single with Shared Bath, 21 meals, tuition, and on site training materials

D = Single with Private Bath, 21 meals, tuition, and on site training materials

E = Commuter Rate with 21 meals, tuition, and on site training materials.

Option	On or Before 9/21/04	After 9/21/04
A - Bunk	$1425	$1625
B - Double with Shared Bath	$1575	$1775
C - Single with Shared Bath	$1875	$2075
D - Single with Private Bath	$2025	$2225
E - Commuter	$1150	$1250

Choose Option:____________________________________

Fees include: tuition, 7 nights lodging, food plan with 21 meals, and on site training materials. Commuter fee includes tuition with 21 meal food plan and onsite training materials. A $500 deposit will reserve your place until October 1, at which time full payment is due.

Fees do not include required texts and videos, round trip airfare and ground transportation to and from Blue Ridge Assembly.

Cancellation & Refund Policy

$50 charge for all cancellations on or before September 1, 2004.
No tuition refunds after October 1, 2004. After October 1 receive a tuition credit for future training with IIQTC.
Refunds or credits will not be issued for late arrivals, unattended events, or early termination of attendance, or lodging/food plan fees.
Any applicable refunds will be mailed to you after November 15, 2004.

By signing I certify that I have read the Cancellation & Refund policy and agree to its provisions.

SIGNATURE: _______________________________________________________________________________

Amount Enclosed: ____________________________

"When you cultivate balance and harmony within yourself, or in the
world -- that is Tai Chi. When you work and play with the essence
and energy of life, nature and the universe for healing, clarity and
inner peace -- that is Qigong."