Wailana Malie Massage Clinic MAE 2105

52-4670 Government Rd.,Kapa'au,HI 96755 (808)854-9283

Email:lomihawaii@lomihawaii.com

Date of Retreat attending__________________
Name_____________________________________________________
first middle last (as it to appear on certificate.)
Date of birth_________________
mailing address___________________________________________
___________________________________________Email:_____________________
telephone numbers- home___________________ soc.sec. #_____________
in case of emergency, notify____________________________________
please list any medical problems, major operations, injuries, etc: _______________________________________________
are you under the care of a physician, psychiatrist, or any other type of treatment? Yes/no
if so please indicate: _____________________________________
please list any medications: ______________________________
have you had any previous experience with bodywork? Yes/no
what types?______________________________________________

Are you a licensed therapist? Give us your License or Massage permit number________________________________________
please tell us why you want to study Hawaiian lomi lomi massage______________________________________________________

_____________________________________________________________

Deposit  of $200.00 is required to register for the Lomi Lomi Retreat in Kona. Balance of $600.00 to be paid on first day of class.

$200.00 Deposit

$600.00 Balance

No refund provided, in the event of an emergency you may apply you fee to the next class May 2010.

Release of liability
the undersign hereby releases any and all liability and/or damage incurred during the course of the  Hawaiian Lomi Lomi Massage Art & Culture Retreat.
Furthermore, the undersigned releases Wesley Sen and Lehua McCandless-Sen, Bishop Museum Amy Greenwell Ethnobotanical Gardens, Makapala Retreat Center, their apprentices and/or agents from any and all damage and liability incurred due to negligence or the undersigned and/or of others.
The undersigned hereby agrees and understands the above:
date: ______________________

signature: _______________________________________________________

printed name: _____________________________________________________