Name_____________________________________________________

Address___________________________________________________

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 airport pickup_______ (Additional $45.00 round trip)
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 Peggy Hill
200 Medicine Way
Eureka Springs, AR 72632