Retreat Registration Form

Mending Medicine Retreat
with John Two-Hawks
At Little Portion Retreat Center on More Mountain
Eureka Springs, Arkansas
OCTOBER 25, 26, 27 & 28, 2007
WEEKEND TWO
Printable REGISTRATION FORM

Name_____________________________________________________
Address___________________________________________________
Phone___________________________
E-mail___________________________
I will be attending______3 Days or    ______4 Days
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 Phil Childers
6907 Village Green Blvd.
Pewee Valley, KY 40056