Half-Day Retreat Registration Form

* First Name

* Last Name

Dharma Name

* Street Address

* City

* State

* Zip Code

* Email

* Phone (w/ Area Code)

* Food Allergies

* Select Retreat Select One 15 Oct 2011 Half-Day Retreat 12 Nov 2011 Half-Day Retreat 10 Dec Rohatsu 2011 Half-Day Retreat 14 Jan 2012 Half-Day Retreat

* Do you have any disabilities or other health issues that we should know about? (Write "None," if you have none.)

* Emergency Contact Name

* Emergency Contact Phone (w/ area code)

Comments or Questions?

Add to Mailing List? Yes