Mending Medicine Retreat - Dayton OH Offline Registration Form

Mending Medicine Retreat
with John Two-Hawks
At The Bergamo Center in Dayton Ohio
August 7, 8, & 9 (DATES TENTATIVE!), 2009
Printable OFFLINE REGISTRATION FORM

Name_____________________________________________________
Address___________________________________________________
Phone___________________________

E-mail___________________________

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:____________

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