residential retreats registration form

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The Beauty and Power of Mindfulness

6:00 pm Wed, May 17 thru 1:00 pm Sun, May 21, 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

_____ room in main house _____ room in barn _____A-frame _____ hermitage

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

If more than 13 people register, would you be willing to share a room?

___Yes ___No Is there anyone you are willing to room with? ______________________

I am paying:

____ $200 deposit; $150 refund with phone call to Dori by May 1

____ PayPal $208; $150 refund with phone call to Dori by May 1

____ Camping deposit $155; $105 refund with phone call to Dori by May 1

____ PayPal $162; $105 refund with phone call to Dori by May 1

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.