Registration for Ren Xue Retreat Ireland
Please provide accurate information and save a copy of this form for your own records. If you need to alter any information or have any questions please email Cathy at
All information you provide will remain confidential.
1. Name *
Given name and surname
Your answer
2. Email Address *
Your answer
3. Address *
Street address
Your answer
4. Phone Number/s *
Please provide the best number/s to reach you on
Your answer
5. What is your age? *
6. Gender *
7. Emergency contact details *
Who can we contact in case of emergency? Please supply name, phone number, email address and relationship to you.
Your answer
8. Do you have any medical conditions we need to know about? *
Please list any important medical conditions you are dealing with at the moment, as well as conditions that may limit your ability to follow the requirements for the Yuan Gong practice. This information will help us with our instructions at the beginning of each session. All information given is regarded as private and confidential. * (If not applicable, enter N/A)
Your answer
9. Dietary Requirements *
10. A limited number of Amatsu treatments are available to book. Please follow the link to find more out about Amatsu therapy; *
11. Total Fee Payable *
12. Please select payment method *
Is there any other additional information you would like to provide?
Your answer
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