Retreat Registration

A five-day retreat led by Fred
Sunday April 30 to Friday May 5, 2017
St. Benedict Lodge, McKenzie Bridge, OR


PLEASE FOLLOW THESE INSTRUCTIONS:
1. Fill out this form from top to bottom.
2. Enter amounts as numerals (e.g., '50' not 'fifty').
3. Click the 'calculate' buttons as you go.
4. Any item marked with (*) in the left column is required.
5. Click the Submit button at the bottom when finished.
6. You will get an email message with your information in it.
7. Print the email message and mail it with your payment.


ATTENDANCE


Will you attend the entire retreat or just part of it?(*)

Please make a selection above

. . . if you selected 'part of the retreat' above, enter the number of nights you will be on retreat.

Enter a number as numerical digits

Do you want to rent linens (sheets, blanket, pillowcase, towels) from the retreat center?(*)

Please make a selection above





Base Retreat fees (prior to subtracting any early bird discount or scholarship credit)(*)

Click the calculate button to set this value



PAYMENT DEADLINE


When will we receive all your fees?(*)

Please select an option above



SCHOLARSHIP REQUEST


Do you need a scholarship? (If paying the full retreat fee is a financial burden, you may request a scholarship for a portion of the fees.)(*)

Please make a selection

. . . if you selected 'yes' above, enter the amount of scholarship you are requesting.

Please enter a dollar amount, as numerical digits.



DONATION TO SCHOLARSHIP FUND


The retreat scholarship fund helps practitioners in financial need attend CSS retreats. Enter the amount you are donating (which must be paid when registering)

please enter a dollar amount as numerical digits.



TOTAL FEES DUE






Total less donation

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Grand total amount due, after adjustments (if any) for scholarship and/or early bird discount.(*)

Click the calculate button to set this value



PAYMENTS


How much of the grand total will you pay now? A $50 non-refundable deposit plus any donation you are making must be paid now (unless your scholarship includes the deposit).(*)

Please enter an amount using numeric digits.





This remaining amount must be received by the deadline date you selected above in order to ensure your place at this retreat.(*)

Click the calculate button to set this value



RETREATANT INFORMATION


Full Name(*)

Please let us know your name.

Your Email - Please double-check that your email address is correct! You will not receive a payment coupon and confirmation of registration if your email address is not correct. (*)

Please provide a valid email address.

Your Phone Number:(*)

Please provide your phone number.

Street Address:

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City, State, Zip:

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Spouse, close friend, or family member we should contact in case of an emergency during the retreat (name, phone):

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Please indicate your general food category

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Please indicate food restrictions due to digestive intolerances.

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Please describe any food allergies, physical limitations, or health/medical issues that we should know about:

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Health care provider, in case of a health emergency during the retreat (name, phone):

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Please indicate if you need a ride, if you have a ride, or if you can offer a ride to someone else:

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If you are attending just part of the retreat, please indicate the day and time you plan to arrive, and the day and time you plan to leave:

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Special needs or requests, or any concerns or questions for the retreat coordinator:

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Please click the box:

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Please carefully review all the information above, then click the Submit button below.