REGISTRATION FORM

The cost of the retreat is $150.00. A deposit of $75.00 is required to hold your spot. The remaining balance of $75.00 is due by May 1st. If you are requesting a scholarship ($75.00) you will need to hold your request with a $40.00 deposit which will be refunded if you are not awarded one. You will know if you are awarded a scholarship by April 25th or sooner. We depend upon women donating to help fund the scholarships.

Name: First and Last*

Email*

Sobriety Date:*

Phone Number:*

Permission to include your phone number on a master list: (yes or no)*

Requesting Scholarship? (yes or no) If yes, deposit required*

DONATION: any amount is helpful:

Prefer to room with: *

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To complete your registration please go toVenmo @Dorothy-Elliott-6 to complete your payment.