Mending Medicine Retreat Registration Form

11th Annual Mending Medicine Retreat
with John Two-Hawks
At The Inn of the Ozarks Convention Center
Eureka Springs, Arkansas
3-DAY Weekend Retreat
OCTOBER 19, 20, & 21, 2012
Printable OFFLINE REGISTRATION FORM

Name_____________________________________________________
Street Address____________________________________________

State/Province & Zip Code_________________________________

Phone___________________________
E-mail___________________________

A non-refundable Deposit of $75.00 is required to hold space

Deposit ($75)____
Paid-in-Full Registration ($160)____
Check____ (Payable to CIRCLE STUDIOS)
Money Order____ (Payable to CIRCLE STUDIOS)
Visa or Mastercard #:_____________________________________

Name on Card:___________________________Exp:____________
For on-site lodging at The Inn of the Ozarks, call: 479-253-9768
Send the original, fully completed Registration Form to:
Mending Medicine Retreat
c/o Peggy Hill
200 Medicine Way
Eureka Springs, AR 72632