Intentional Health Hawaii and Intentional Health California
Colonic Certification Retreat
At The Hawaiian Sanctuary, Pahoa, Hawaii
Saturday October 6th – Saturday October 13th, 2018
Facilitators: Terra Ann Pracht CHT and Lynda Newton MT, CHT
With Special Guests
Registration Information & Agreement Form
Please READ and fill out this form COMPLETELY to register.
Include your initials in designated areas, make a copy for yourself
and mail the ORIGINAL, along with your payment to:
Intentional Health Hawaii Inc.
P.O. Box 1222
Pahoa, HI 96778
PHONE: __________________________ EMAIL: _________________________
(The one you use most) (The one you check most)
EMERGENCY CONTACT NAME: _________________________________________
(Person not traveling with you)
EMERGENCY CONTACT PHONE: _________________________________________
HOW DID YOU HEAR ABOUT US? ________________________________________
Please answer the following questions regarding your colonic retreat experience (use separate sheets or the back of this form if needed):
* Intentional Health Hawaii Inc. collects this information to get to know you. All answers are seen only by our facilitators and kept confidential. We do not discriminate based on age, race, religion, sexual orientation or background.
Questions are offered to better serve you as a student of our Training Program. We reserve the right to refuse an applicant.
We take pride in creating a safe space of acceptance, healing and unconditional love. We do not claim, nor desire to be an alternative for proper medical or psychological care. All applicants are screened and treated equally.
1. Are you now practicing CHT (colon hydrotherapy) or have you in the past practiced CHT?
2. If yes, how long did you practice?
3. If yes, where are you practicing now?
4. Are you certified?
6. Please tell us why you would like to be CHT certified.
7. What subject/topic excites you most about this training, and Why ?
8. Which specific aspects of this “Retreat Training Experience” attracted you?
9. List your Goals/Intentions as you embark on this tropical transformation adventure:
10. Do you have a religious/spiritual practice? _____ Please tell us a bit about it.
Please answer the following questions regarding your medical/health history (use separate page if needed):
1. What medications are you currently taking? ______________________________________
2. Do you have any allergies? ______ If so, list specifics and what you do to prevent or treat them.
3. Are you currently suffering from an injury? ______ If so, please describe in detail: Where in/on your body, the diagnosis from your physician, what happened and what you are doing to nurture healing.
4. Make sure you have all necessary medications with you. Please let us know about any dietary restrictions, allergies, health conditions or special needs you may have.
5. On a scale from 1 – 10 (1 being poor and 10 being perfect), rate your emotional and mental health. ______
Explain why you chose this number:
OTHER PERTINENT INFO
*As a student/graduate of Intentional Health and Intentional Health Hawaii Inc., you will receive a certification from the training retreat and curriculum book.
*Graduation and certification will be contingent upon the student’s successful completion of the curriculum which includes lectures, testing and hands-on, practical application of the course material.
*Classes are given in English, students must be able to speak, read and write English proficiently.
*It is your responsibility to be proactive about the health and safety of your body temple.
*We always recommend purchasing travel insurance in case you have to cancel or leave early for any reason.
______ (initial) I hereby release Lynda Newton, Terra Ann Pracht, all guest teachers, Intentional Health/Intentional Health Hawaii Inc., Mile Marker 12, LLC, Mile Marker 12 Farms, Inc., and Hawaiian Sanctuary, Inc. from any liability or responsibility having to do with my personal health and physical safety during travel from October 6th – October 13th, 2018.
______ (initial) I also understand that I cannot hold Lynda Newton, Terra Ann Pracht, all guest teachers, Intentional Health/Intentional Health Hawaii Inc., Mile Marker 12, LLC, Mile Marker 12 Farms, Inc. or Hawaiian Sanctuary, Inc. responsible for my personal health on this trip. I accept that all staff provides, within their abilities, everything they can to make this training retreat as safe and pleasurable for me as possible. I will do my part in using common sense and positively participating with the group activities.
______ (initial) I agree to show cooperation and respect to retreat leaders and fellow retreat attendees. If I am asked to leave the retreat by the retreat leaders for any behavior that is considered to be unprofessional, unethical or disruptive, there will be no refund of any payments made.
______ (initial) I acknowledge that I am not obligated to participate in any or all of the activities or meals provided but my payments will be utilized for the planned activities and meals regardless of my participation.
______ (initial) Intentional Health/Intentional Health Hawaii Inc. reserves the right to adjust accommodations, schedules and food at Mile Marker 12 Farms, Inc./ Hawaiian Sanctuary, Inc. as needed. I understand that, due to the nature of group travel and circumstances beyond our control (weather, traffic, delays, etc.), schedules and venues are subject to change without notice. As a good student of the colonic retreat, I will do my best to “go with the flow” and be flexible.
________ (initial) I understand that any and all pictures or videos taken by the facilitators are the property of Intentional Health, Intentional Health Hawaii Inc., Mile Marker 12, LLC, Mile Marker 12 Farms, Inc. and Hawaiian Sanctuary, Inc. and if used, will only be used for the sole purpose of promoting said entities.
________ (initial) I understand that video or audio recordings of any type by students are not permitted during any of the class sessions. Cell phones must be turned off while classes are in session.
________ (initial) I will try to learn as much as possible while having as much fun as possible.
ASSUMPTION OF RISK
_____ (initial) I am aware that participation in the Intentional Health/Intentional Health Hawaii Inc. Training Retreat, hosted by Mile Marker 12, LLC, Mile Marker 12 Farms, Inc. and Hawaiian Sanctuary Inc., may be a hazardous activity. I acknowledge that a certain minimum level of physical health, strength, fitness and flexibility will be required. I am voluntarily participating in these activities with knowledge of the risks of injury for which I will voluntarily assume.
_____ (initial) I acknowledge that I have read the LIABILITY RELEASE and agree to the terms outlined in this entire document.
As consideration for being permitted to participate in Intentional Health/ Intentional Health Hawaii Inc., activities, outings and travel, I hereby agree that I, myself, my assignees, heirs, guardians and legal representatives will not claim against, sue or attach the property of Lynda Newton, Terra Ann Pracht, and all guest teachers, Mile Marker 12, LLC, Mile Marker 12 Farms, Inc., and Hawaiian Sanctuary, Inc. for injury for damage resulting from my participation in any lesson, class, workshop, excursion or activity.
I hereby release Lynda Newton, Terra Ann Pracht, all guest teachers, Mile Marker 12, LLC, Mile Marker 12 Farms, Inc., Hawaiian Sanctuary, Inc. and all agents and heirs from any and all such actions, claims or demands that I, my assignees, heirs, guardians and legal representatives now have or hereafter may have for injury or damage associated with my participation in ANY offerings of Intentional Health/Intentional Health Hawaii Inc. and for all claims, injury damages or liability suffered by me in connection with my retreat to Hawaii.
Individuals hereby acknowledge that before participating in any program that they should consult with a physician. I have carefully read this entire agreement and fully understand the above contents. I am aware and agree that this is a complete release of liability, voluntarily assumed for my participation in all activities with Intentional Health/ Intentional Health Hawaii Inc., Mile Marker 12, LLC, Mile Marker 12 Farms, Inc., and Hawaiian Sanctuary, Inc.
Printed Name _________________________________________________________
Signature _____________________________________ Date __________________
Information and services provided are not intended to prescribe, recommend, diagnose or treat a health problem or disease. They are not a substitute for medical care. If you have or suspect you may have a health problem, you should consult your primary health care providers.
Copyright © 2013 Intentional Health / Intentional Health Hawaii – All Rights Reserved
Space is limited for this unique training retreat, please
make your reservation early to guarantee your attendance.
Pricing Options (Please check only one)
(A deposit of $500.00 is required to reserve your space)
* All Option prices include Hawaii State Taxes
Option A and B prices include accommodations, tuition and most meals (6 breakfasts, 6 lunches).
Do bring extra spending money for shopping, three outside meals, optional healing treatments (i.e. massage) and tips for chefs/therapists.
A. ( ) $3,695.00 (one person, private single room)
B. ( ) $3,195.00 (shared room)
C. ( ) $1,995.00 (local stay/Kama Aina) meals not included, inquire about purchase of meals.
*Early bird Special – if signed up and paid-in-full before June 1, 2018, your price will be discounted $200.00!
_______ (initial) I understand that I am responsible for purchasing my airfare.
I am aware that all classes, room and board are based on arrival October 6, 2018 and departure October 13, 2018.
_______ (initial) I agree to cover all additional personal costs incurred, such as market shopping, massages, special services/needs medical care and tips.
_______ (initial) I understand that transportation is not included. Airfare to Hilo International Airport and shuttle fees are the responsibility of the participant. Bring spending money for tips, snacks, shopping and farmer’s market.
Payment options: (ALONG WITH THIS COMPLETED APPLICATION)
( ) Cash (Kama Aina, long term visitors)
( ) Money Order ( ) Check
Please make payable to: Intentional Health Hawaii and mail to Terra Ann Pracht, P.O. Box 1222, Pahoa, HI 96778
( ) Credit Card If you are paying by credit card, please include an additional 4% processing fee. For Credit Card instructions, contact Terra Ann.
For Questions Contact: Terra Ann of Intentional Health Hawaii Inc.
toll free: 800.309.8010 * mobile: 310.261.2587 * fax: 808.748.0033
PAYMENT AND REFUND POLICY
*A deposit of $500.00 is required to reserve your space.
*Any remaining balance is due on or before September 13, 2018.
*Payments received after September 13 but on or before September 27, 2018 will incur a $150.00 late charge.
*Registration closes and no payments will be accepted after September 27, 2018.
*Refunds requested before September 1, 2018 will be refunded in full, less a $50.00 processing fee.
*Refunds requested on or after September 1 but on or before September 27, 2018 will be refunded in full, less a $150.00 processing fee.
*There are no refunds after September 27, 2018.
*Any requests for refunds will be processed within 30 days of the request.
*Any adjustments in travel plans are the responsibility of the participant.
*Intentional Health/Intentional Health Hawaii Inc. is not responsible for any fees associated with any cancellations or changes.
_______ (Please initial) I have read and understand the payment and refund policy above.
* Additional comments or questions (such as roommate requests)?
Please address them here:
*PLEASE MAKE A COPY OF THIS ENTIRE FORM
FOR YOURSELF BEFORE MAILING.*
If faxing, please make sure that you have faxed both sides, if used.
Mahalo (thank you) for joining us in this unique training retreat,
we are excited and are looking forward to providing you with a
one-of-a-kind experience in a beautiful environment.
Terra Ann Pracht and Lynda Newton