Adoption Healing Weekend Registration
Over 30 years of helping those whose lives have have been touched by adoption
  If you are paying by Credit Card, the address you give must be the address at which you receive your Credit Card Bill.  SiteLock
   *  = Required
 *  Salutation   Mr.    Mrs.     Ms.       *  First:           *   Last: 
 *  Street 1:                     Street 2:   
 * City:    * State/Prov:      Zip:    * Country:  
 *Home Ph:   Bus. Ph:   Cell:  *I am: Adoptee Natural Mom
* 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 to be used within 1 year or the fee is forfeited.

** Please get travel insurance to protect yourself in case you are unable to attend.
*   By placing an 'X' in the box to the left, I  agree to the following 2 items: 
     1.)  That I will not be allowed to attend the weekend if I am in any way ill. (severe cold, cough, flu, etc.)
    2.)   That I will have to return home without attending if i arrive ill in any way.
** Please get travel insurance to protect yourself in case you are unable to attend.

 *  Healing Weekend $200 USD                                                                            $125 deposit required
   
  Reunited Pairs Weekend $200 USD                                                                $125 deposit required  
      Healing/Vacation Week in Caribbean $999 USD                                          $500 deposit required

(The price of the weekends is negotiable in case of financial hardship)

** $25 will be donated to Covenant House New York's Mother/Child program   from each $200 fee.

** All fees are non-refundable
         

* 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.
Please press the SUBMIT button below


Signature _______________________________________        Date ________________

You may make your payment by faxing your Name and Credit Card info to: 845-267-2736,
or you may send the above form with payment via US Mail
.

You must, no matter how you pay, send this form with your signature and date of signing to us by fax or to mail it us at the address below

Adoption Healing, 74 Lakewood Drive  Congers, NY 10920-1710

If paying by check, make the check payable to Adoption Healing.

   E-mail us at joesoll@adoptionhealing.commailbox


Last Updated on November 10, 2013  by Joe Soll               
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