residential retreats registration form

Waking Up to the Love That is Here   Waitlist
May 30 – June 3, 2018 * Kairos * Dori Langevin

Name:_____________________________________________________Age:_______

Full Address:___________________________________________________________

Phone Cell: ______________________ E-mail: _______________________________

Please describe your previous 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

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

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

 

I am enclosing registration fee of:

____ $200 ($100 refund with phone call to Dori by May 2)
____ PayPal $207 ($100 refund with phone call to Dori by May 2)

____ $132 Camping ($32 refund with phone call to Dori by May 2)
____ PayPal $137 Camping ($32 refund with phone call to Dori by May 2)

In addition, I would like to contribute $_______ to the scholarship fund.
Thank you for your generosity.

By signing below, 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.