residential retreats registration form

Radiant Mind ~ Open Heart: 
Awakening from the Illusion of our Separateness
6:00 pm Wed, Sept 20 thru 1:00 pm Sun, Sept 24, 2017

Name:________________________________________________________________

Address:______________________________________________________________

Phone: ______________________ E-mail: __________________________________

Please describe your retreat experience (if this is your first retreat with Dori):

 

Please describe your intentions/aspirations for your retreat experience:

 

Lodging request: Please indicate 1st and 2nd choices or ___ no preference

____A-frame    ____hermitage    ____ room in main house      ____room in barn

Please describe any physical ability needs related to your lodging request:

If more than 13 people register, are able and willing to share a room?
___Yes   ___No    Roommate preference?: ______________________

I am enclosing:
____ $200 deposit; $150 refund with phone call to Dori by Sept 6
____ PayPal $207; $150 refund with phone call to Dori by Sept
____ $132 Camping deposit; $82 refund with phone call to Dori by Sept 6
____ PayPal $137 Camping deposit; $82 refund with phone call to Dori by Sept 6
509-688-7772
In addition, I would like to contribute $_______ to the scholarship fund. Thank you for your generosity.
I understand and agree to the refund policy for this retreat:

_______________________________                   ______________________________
Signature                                                                  Date
Please sign & mail this registration form to Dori at: 4612 So. Schafer Branch Rd, Spokane, WA 99206
with a check payable to Dori Langevin or a copy of your PayPal receipt.