Retreat for Women in Recovery (Nov 25-27, 2022) To register, please complete this form and submit with the required $50 non-refundable, non-transferable deposit. Required information marked with *Your TitleMr.Mrs.Ms.Fr.Sr.Dr.Name* First Last Suffix: Age: Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:* Phone Type* Home Mobile Business Email:* Special needs: First floor room Diabetic diet Vegetarian diet Is this your first retreat?YesNoYour Retreat Group, if any? Additional Comments:Non-refundable, non-transferable Deposit* $50 Payment Method:* Credit Card eCheck Credit Card American ExpressDiscoverMasterCardVisaJCBMaestroSupported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name eCheck Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount Type
