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A five day CSS retreat led by Todd
Friday April 12 through Wednesday April 17, 2013.
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 and mail the email message with your payment.
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| Will you attend the entire retreat or just part of it? (*) |
Please make a selection above |
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| Number of nights (if not attending entire retreat) |
Enter a number |
If you selected 'part of the retreat' above, enter the number of nights you will be on retreat. |
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| Retreat fees (*) |
Click the calculate button to set this value |
Fees for your retreat (includes room and board). |
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| When will you pay all your fees? (*) |
Please select an option above |
The early bird discount is available only if you are attending the entire retreat and pay all fees by the earlier deadline. |
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| Do you need a scholarship? (*) |
Please make a selection |
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| Scholarship amount requested |
Please enter a dollar amount |
If you selected 'yes' above, enter the amount of scholarship you are requesting. |
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| Adjusted total fees (*) |
Click the calculate button to set this value |
The total fees for your retreat, after adjustments (if any) for scholarship and/or early bird discount. |
| How much will you pay right now? (*) |
Please enter an amount |
At least $50 must be paid now as a non-refundable deposit in order to register (unless you are requesting a full scholarship, which includes the deposit). |
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| Balance due by deadline (*) |
Click the calculate button to set this value |
This amount must be paid by the deadline date you selected above. |
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| Your Name (*) |
Please let us know your name. |
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| Your Email (*) |
Please let us know your email address. |
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| Your Phone Number |
Invalid Input |
Your telephone number, in case we need to contact you about your registration |
| Street Address |
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| City, State, Zip |
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| Dietary Restrictions |
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Please indicate if you have any dietary restrictions. |
| Health Issues |
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This retreat will take place in a rural area, and there are no physicians or health care professionals on staff. Please describe any health or medical issues that we should know about. |
| Health Care Provider (name, phone) |
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Contact in case of a health emergency during the retreat. |
| Emergency Contact (name, phone) |
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Spouse, close friend, or family member whom we should contact in case of an emergency during the retreat. |
| Transportation Plans/Needs |
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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. |
| Partial Retreat Details |
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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. |
| *required |
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