La'akea Registration Form

Name: _______________________________________________________________

Which course are you registering for? Please include the dates of the course.

_____________________________________________________________________

Address: ______________________________________________________________

______________________________________________________________________

Phone #s : ______________________________________________________________


Email: ________________________________________________________________

Date of Birth (optional) : ___________________

Lodging Preference: Camping (bring your own tent) ____ Dorm Space____ Offsite____

Special Health Needs/ Dietary Preferences (vegan, dairy-free, wheat-free, etc.):

______________________________________________________________________

In case of an emergency who should we contact?

Name: ________________________________________________________________

Relationship: _____________________________Phone:________________________

Amount Enclosed $_____________ Amount Due $____________

The Deposit amount as requested in the Course Description in non-refundable, unless La'akea cancels the event, in which case a full refund will be provided. Funds received prior to the event in excess of the deposit will be returned should you choose to cancel. Please let us know immediately if you need to cancel.

Please print, fill out and mail to:

La'akea Community
PO Box 1071
Pahoa, HI 96778
(808) 443-4076
email: '>
http://www.permaculture-hawaii.com