Mending Medicine Retreat Registration Form

Mending Medicine Retreat
with John Two-Hawks
At Little Portion Retreat Center on More Mountain
Eureka Springs, Arkansas
4-DAY Weekend Retreat
OCTOBER 21, 22, 23 & 24, 2010
Printable OFFLINE REGISTRATION FORM

Name_____________________________________________________
Street Address____________________________________________

State/Province & Zip Code_________________________________

Phone___________________________
E-mail___________________________
Would like to share a room with:____________________________
Diet:
Vegetarian____ Regular____ Special_________
Deposit: $75.00 (non-refundable, required to hold space)
Check____ (Payable to CIRCLE STUDIOS)
Money Order____ (Payable to CIRCLE STUDIOS)
Visa or Mastercard #:_____________________________________
Name:____________________________________Exp:____________
Will arrive:___________________
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