Lapis Lazuli Light

Workshop Registration Form

Workshop Name: __________________________ No:________

Workshop Dates: ______(M)______(D)______(Y) to ______(M)______(D)______(Y)

Basic Information	Name		Gender	q Male q Female
	Home Address
	Home Phone		E-mail
	Date of Birth		Religion
	Education		Major
	Company		Job Title
	Company Address		Business Phone
Health Condition	Health Condition		Blood Type
	Current Illness		Current medication taken
	Past Illness with its duration
	Current symptoms	tired, headache, back ache, Others____________________	Dietary Habits	q vegetarian q raw diets q non-vegetarian
	Interests	painting, music, fitness, reading, Others_____________________	Dietary Preferences (Circle all that applies)	brown rice, white rice, bread, milk, meat, cooked vegetables, raw vegetables, root vegetables, sea vegetables
About Yourself	How do you see yourself?
	What is your perspective on life in general?
	What I like most about myself is...
	What I most wish to change is¡K
	What is your motivation for attending this workshop?

When completed please mail this form and check for workshop fee to:
LLL, PO Box 42530, Santa Barbara, CA 93140