TO REGISTER PLEASE COMPLETE THIS FORM AND FAX OR MAIL IT TO:

ATTENTION: Jeffrey Chand at 250-384-1702 (fax)

MAIL: 320-1105 Pandora Ave, Victoria, BC V8V 3P9

For questions please email coastalmed@shaw.ca or call 250-384-1700. If you are calling please leave a
message and your call will be returned.

Full Day Workshop: Qi Gong for Health, Vitality & Longevity

Saturday, August 21, 2010
Camosun College, Wilna Thomas Room
9:00 am – 3:30 pm

Please register me for the Qi Gong workshop stated above.

I have enclosed a cheque or credit card number for the following amount listed below:

Price: GST: PST: Total: Name of Attendee:

5% 7%
95.00 4.75 6.65 $106.40
Payment can be made by visa, mastercard or cheque. Cheques should be made payable to: Coastal
Integrated Medicine and may be post-dated to August 14, 2010 and mailed to the above address.
Confirmation of your registration will be emailed to you upon receipt of registration. Receipts will be
issued at the workshop.

Name: ___________________________________________________________

Street address: ____________________________ City: ___________________

Province: ________________ Postal code: _____________________________

Phone: ___________________ Email: __________________________________

Credit card #: ____________________________________ Type:

____________

________ Cardholder’s name:

Expiry Date:
______________________________

Waiver and Release: Regarding my participation in the “Qi Gong for Health Vitality & Longevity” workshop conducted by Jeffrey
Chand, I, the undersigned, agree to hold harmless, indemnify, and release Jeffrey Chand and Coastal Integrated Medicine from all
liability for damage or injury to myself or any person or property resulting therefrom. I accept full responsibility for damage or injury
which may result. I have read, understood and agree with all of the preceding statements in this waiver and release:

Signature: ________________________________________ Date: _______________________________________________

Registration must be received one week prior to the course. Late registrations will be accepted on a space available basis. Cancellation
must be confirmed in writing five days in advance.

Please wear comfortable loose clothing. Pack a lunch or you are welcome to eat out.