Mending Medicine Retreat
with John Two-Hawks
At Country Mountain Inn
Eureka Springs, Arkansas
3-DAY RETREAT & REUNION CELEBRATION!
OCTOBER 23, 24 & 25, 2009
Printable OFFLINE REGISTRATION FORM
Name_____________________________________________________

Address___________________________________________________

Phone___________________________
E-mail___________________________

Call Country Mountain Inn to Reserve Your Room: 479-253-7120

Diet:
Vegetarian____        Regular____          Special_________

Deposit: $50.00 (non-refundable, required to hold space)
Check____ (Payable to CIRCLE STUDIOS)
Money Order____ (Payable to CIRCLE STUDIOS)
Visa or Mastercard #:_____________________________________

Name:____________________________________Exp:____________

Will arrive on:___________________

Need directions_______  Send them e-mail____   or snail mail____
Snail mail directions to:_______________________________________

Send the original, fully completed Registration Form to:
Mending Medicine Retreat
c/o Phil Childers
6907 Village Green Blvd.
Pewee Valley, KY 40056