| *
Salutation Mr. Mrs.
Ms.
*
First:
*
Last: |
| *
Street
1:
Street
2
: |
| * City: *
State/Province
Zip: * Country: |
| * Home
Telephone.:
Business Telephone.:
*
I am: Adoptee
Natural
Parent |
| * E-mail: * Confirm
E-mail: |
| *
I
wish
to
borrow
a
sleeping
bag
Do you
have
a car? * Food Requirements:
|
| * By
placing
an
'X'
in
the
box to the left, I agree to wait until my weekend is confirmed
to make my
travel arrangements and I assume all responsibility for my travel costs. |
* By
placing an 'X' in the box to the left, I
agree to the
following 2 items: 1.)
I
understand and agree that
the fees for these weekends are non-refundable.
2.)
If
a
replacement for my spot is found, a $75 cancellation
fee
will be charged and
the remainder of the fee that I paid will be applied to a
future weekend.. else the
fee is forfeited.
We suggest you take out
travel insurance to protect yourself in case you are unable to attend.
|
*
Healing
Weekend $250 USD
(Non-Refundable)
$150 deposit required
Reunited Pairs Weekend
$300 USD (Non-Refundable)
$150 deposit required
Healing/Vacation
Week
in
Caribbean
$999
USD
(Non-Refundable)
$500
deposit required
** Proceeds of
all weekends pay the rent for our New York City Office
*
Date of Weekend
Your
balance
is
due
four
weeks
prior
to
your
weekend
|
Payment
Information
|
| *Amount
of
Payment
*
Pay
by
Name
on
Card |
| Card Number
Card
Expires * Security
Code What
is the security
code? |
| Comments
If
Not
paying
by
credit
card,
enter
00
in
the
Security
Code
Box
above.
|