| *
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: |
| * Emergency
Contact: *
Relationship to you *Phone
|
| Facebook
name: Facebook URL |
| *
Have you been in therapy for
adoption issues?
If so, for how long ?
Your age ? |
| * Borrow a sleeping bag
?
Do
you have a car? * Food
Requirements:
|
| *
By placing an 'X' in
the box to the left, I agree to attend Chat on a
regular basis or if i cannot, then i will attend a
free on line information session. |
*
By placing an 'X' in
the box to the left, I acknowledge that there are
cats at the weekend.
I agree to bring my own allergy
medicine if I am allergic. |
| *
By placing an 'X' in
the box to the left, I agree to sleep at the retreat
location... |
| *
By placing an 'X' in
the box to the left, I agree to bring my own
towels... |
*
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
Date of Weekend Your balance is due four weeks
prior to your weekend
|
Payment
Information
|
| Payment Amount
Pay
by
Name on Card |
| Card Number Card Expires
Security Code What
is
the security code? |
|
If you are Not paying by credit card, enter 00 in
the Security Code Box above. |