Mingles for Singles Registration Form

MINGLES FOR SINGLES
REGISTRATION FORM
(print and mail this form along with your payment to the address below)

I am applying for:

_____ Mingles Orientation Interview - $150 (pre-requisite before admission to any Mingles Groups.

Date/time I'd like to have my interview ___________________

Mingles for Singles Dating & Relationship Group (Fridays, 7PM)
_____ $25 single admission. Date I'd like to attend __________________

Mingles Mixers (4th Friday of the Month, 7PM)
______ $25 single admission. Date I'd like to attend __________________

Mingles Speed Dating (3rd Friday)
______ $25 single admission. Date I'd like to attend ________________

______ $200 for 10 coupons. Good for Mingles for Singles Group, Mingles Mixers, Speed Dating

______ Mingles Introduction Service - $150

______ Annual Membership $1000

First Name _______________________________ Last Name ______________________

I am male ____ female _____ *Birth date: Month ________ Day ________ Year ______

Email _________________________________

Telephone:    Home (____)_______________________

                    Work: (____)_______________________

                    Cell:   (____)_______________________

Address: Street _________________________________ City: _________________________________

State/Province: ___________________________ Zip: ______________

Country: _______________________

______ I verify that I am at least 18 years of age*.

*(You must be 18 or older. Positive ID showing proof of age is required)

I am:

____ Divorced
____ Never Married
____ Widowed

(We have groups for all relationship structures, styles and sexual orientations. However, you must be single to attend Mingles for Singles. We have other groups for couples).

What relationship structure would you like best? (If more than one apply, number in order of preference).

_____ monogamy
_____ serial monogamy
_____ committed relationship
_____ not committed
_____ fidelity
_____ polyamory *
_____ swinging/lifestyles *
_____ polyfidelity *
_____ open relationship *
_____ open marriage *
_____ single and dating
_____ tantra
_____ married *
_____ other (please explain) ____________________________________________

* If you check any of these options, you are not eligible for Mingles for Singles. You may attend our other Dating Groups designed for Lifestylers.

What is your sexual orientation? ________________________________________

Height ____________ Weight _____________ Body Type ____________

Write the following. Use additional paper if necessary.

Describe your physical appearance __________________________________________________________________

Describe your Personality:_________________________________________________________________________

_______________________________________________________________________________________________

What are your best qualities? _____________________________________________________________________

What are your faults? ____________________________________________________________________________

What are your interests? _________________________________________________________________________

______________________________________________________________________________________________

What do you seek in relationship? __________________________________________________________________

_______________________________________________________________________________________________

What do they look like? ___________________________________________________________________________

What are their qualities? __________________________________________________________________________

_______________________________________________________________________________________________

What are their interests? __________________________________________________________________________

_______________________________________________________________________________________________

If everything turned out the way you wanted, what would that look like? ____________________________________

_______________________________________________________________________________________________

I'm also interested in the following:

___ Counseling $150/hour, ___ hours Date I'd like to attend _______________

___ Holotropic Breathwork/Spiritual Emergence $500, ___ hours Date I'd like to attend _______________

___ Voice Dialogue $150 hour, ___ hours Date I'd like to attend _______________

___ Tantra Coaching $150/hour, ___ hours Date I'd like to attend _______________

___ Adore Aphrodite $150/hour, ___ hours Date I'd like to attend _______________

___ Delight Dionysius $150/hour, ___ hours Date I'd like to attend _______________

___ Share Shakti & Shiva $150/hour, ___ hours Date I'd like to attend _______________

___ Alternative Lifestlyes Counseling $150/hour, ___ hours Date I'd like to attend _______________

___ Personal Growth Coaching $150/hour, ___ hours Date I'd like to attend _______________

___ Dreamwork $150/hour, ___ hours Date I'd like to attend _______________

___ Existential Life Review $150/hour, ___ hours Date I'd like to attend _______________

___ Hypnotherapy, Childhood Regression $150/hour, ___ hours Date I'd like to attend _______________

___ Past-Life Regression, Future-Life Progression $150hour, ___ hrs Date I'd like to attend _______________

___ Gestalt Therapy $150 hour, ___ hours Date I'd like to attend _______________

___ Spiritual Releasement Therapy $150 hour, ___ hours Date I'd like to attend _______________

___ Alien Experience Integration $150 hour, ___ hours Date I'd like to attend _______________

___ Vini Yoga Private Instruction $85 hour, ___ hours Date I'd like to attend _______________

___ Vini Yoga Group Classes $15 per person Date I'd like to attend _______________

___ Polyamory Connection Group $200/10 weeks

___Polyamory Connection single admission: $25 Date I'd like to attend _______________

___ Break the Godspell Study Group $200/10 weeks

___ Club Tantra Annual Membership $150 c, $100 s

___ Club Tantra Etiquette Class $150 Date I'd like to attend _______________

___ Club Tantra Party $100 (couple, single men) Date I'd like to attend _______________

___ Club Tantra Party $50 (single women) Date I'd like to attend _______________

___ Tantra School $595 single Date I'd like to attend _______________

___ Tantra School $995 pair Date I'd like to attend _______________

___ Holotropic Breathwork Group Class $125/day

___ Voice Dialogue Group $125/3 hours

___ Existential Life Review Group $125/3 hours

___ Dreamwork Workshop $125

___ Gestalt Therapy Workshop $125

Signature: __________________________________________

PAYMENT BY: _____ CHECK / _____ VISA* / ____MC* / ____ MONEY ORDER _____

CREDIT CARD INFORMATION
Credit Card payments will appear on your statements as paid to “World Tantra Association”

Name on Credit Card (including any middle initial):

First __________________________ Middle Initial _____

Last ____________________________________

Complete Billing address on Credit Card:

Street ________________________________________________

City ______________________________

State/Providence _________________________________

Zip _______________________

Country ___________________

Credit Card Number: ___________________________________

Expiration date :_____/______/

Signature: _________________________________________

(I hereby authorize this transaction and agree to the terms on this form).

No refunds on the day of the event or 5 days prior to the event.

CANCELLATION FEES
90 days or more - 25% of price
60 days or more - 40% of price
31-59 days - 50% of price
6-30 days - 75% of price

Mail registration form, copy of ID showing proof of age and a check or money order payable, to:
World Tantra Association, 1371 Malaihi Road, Wailuku, Maui, HI 96793 (808) 244-4103
If you wish to fax your completed form and are paying by credit card, call 808-244-4103 and we'll switch over the phone to receive your fax.