Please print this form, provide all requested information and necessary payments, and mail to the address listed below. If you have any questions, you may contact Darcy Lubbers, MFT directly via email, Darcy@magicofhealing.com or phone, 310.452.7799. A fax number is also available.

YES! I want to enroll in the Life in Balance Retreat in Kauai, Hawaii, April 21—28, 2007

Please keep me on your mailing list for future retreats and classes.

Name:

Address:

City, State, Zip:

Phone (H):

Phone (W):

Email:

My nonrefundable deposit of $350/person is enclosed. (Balance due by March 15, 2007)
My entire "earlybird" workshop fee of $1,395 is enclosed. (If paid by February 5, 2007)
My entire workshop fee of $1,495 is enclosed. (If paid between February 6 and March 5, 2007)
My entire workshop fee of $1,545 is enclosed. (If paid between March 6 and April 5, 2007)

Additional Discounts: A $50 discount is available for senior citizens, full-time students, and groups of two or more. Evidence of senior status, or full-time student status must be included with application. Only one discount may be used; no discounts may be combined.

Please include my discount of $50 allowed for the Life in Balance workshop, bringing my total payment to __________. I am: A Senior Citizen A Full-time Student A Group
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Additional Offering at the Retreat:
Would you like to receive instruction in Primordial Sound Meditation during the retreat? The customary cost for this special instruction is $325/person. It will be offered at the retreat at the greatly discounted cost of $135/person.
Please add my fee of $135 for instruction in Primordial Sound Meditation, bringing my total payment to __________. Please include the following information:

Birth Date:________________ Birth Time (if known):_______________

Birth Location: ____________________________________
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Note to Health Professionals: Please add a $15 administrative fee, along with your professional license information if you would like to receive continuing education credit for the Life in Balance workshop.

Please add my administrative fee of $15 for continuing education credit for the Life in Balance workshop, bringing my total payment to __________. My professional license #_______________.
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Method of Payment
Check  (Please make checks out to Darcy Lubbers, ATR, MFT)
Money Order 
Visa 
MasterCard 
American Express

Account Number: 

Name on Card: 

Expiration Date:  Code: 

Signature: 

Mail your completed form with payment to:

    Darcy Lubbers, ATR, MFT
    Magic of Healing West
    2727 Main Street, Suite E
    Santa Monica, CA 90405

Calculations/Tuition Refunds
• Cancellations received up to eight weeks before the workshop starts are refundable, minus the $350 nonrefundable deposit.
• Cancellations received up to six weeks before the workshop starts are refundable, minus a $450 nonrefundable administrative fee.
• Cancellations received up to four weeks before the workshop starts are refundable, minus a $600 nonrefundable administrative fee.