QINWAY QIGONG Energy Recharge Workshop

Special Ability Rejuvenation 3.2 D Retreat REGISTRATION

Prefer send registration form via e-mail or fax. Email: [email protected] Fax: 510-291-2962 A registration form must be submitted with a registration fee. The information in the form must be real and truthful.

Please Note: We will not accept students with terminal cancers, mental illnesses, or any infectious diseases.

Easy Step 1: Fill out all fields. A completed registration form will assist Grandmaster design a complete healing system for you. Planned attending Date: ______

Name Sex Birth Education Date (Degree, Major) Address (including City, State E-mail and Zip) Phone Website Race Day Night Mother Country Job Religion Driver License #

Average Annual Native SSN # Income Language

Height Weight Weight (your scale) (Qinway scale) List problems that you hope to solve

List any family health problem(s)

Any history of mental illness Can you take care of yourself Who live with you（including animal） and their health Family member(s) support your retreat & Bigu

1 Do you have any experience of natural healing or spiritual practice?

Meat & Diet vegetarian Bowel Irregular Are you on Yes movements medication? Vegetarian Regular No

How did you hear Referred by a friend. Who? Flyer. Where? about Qinway? Ad. Which ad? Magazine. What? Internet. Which search engine/link? Other. What?

Step 2: Pay Registration Fee

Registration $1885 ($1,800 + 4.712% Hawaii Exercise Tax), Non-refundable. fee $1,885 Interested in Private Healing session with Grandmaster? If you sign up for both, please add (non-refundable) $188 (180 + 4.712% Hawaii Exercise Tax) for private healing session registration to the retreat registration.

Tuition $1,885 $1885($1,800 + 4.712% Hawaii Excise Tax), Non-refundable. (Payable on You may bring Cash, Cashiers check, money order, or check with a copy of your photo ID on the the retreat day) retreat day. Three day Bigu supplies are included in tuition. After the retreat, additional fees are required for healing food and Fenshui energized objects. Bigu supplies are $36 each for every 3 days.

1. Cashiers check, Money Order or Check payable to Qinway Payment Methods P O Box 61864 (Select ONLY one Honolulu, HI 96839 payment method) 2. Wireless Transfer: . Qinway . Bank of Hawaii Routing (swift code) #1213-01028 . Swift Code: BOHIUS77XXX . Account Number: 000-292-4900 3. Online Visa/MC Card. Note:  Photo ID must be submitted with personal check.  Processing fee for money order or cashiers check vary depending on institutions.  Additional fees are required for online Visa/Master Cards. The total is $1905.00 ($1885 + $20 of credit card fee). For more information, click here.  Corporate or Non-US based credit cards will be charged 1.37% additional processing fee paid to Visa or MasterCard companies. The total is $1931.00 ($1885 + $20 of credit card fee + $26.00 of Corporate or Non-US based credit card fee). For more information, click here.

2 Signature I understand that the registration fee is non-refundable under any circumstance, and I have read and agree with all program descriptions available at www.qinway.org.

PRINT YOUR NAME:

SIGH HERE: DATE:

Thank you! Qinway Grandmaster Foundation P O Box 61864 Honolulu, HI 96839 www.qinway.org