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2010 Retreat Registration Form

The Theme Within

JPD W & R Retreat 2010 Registration

Register early:  space is limited!

Please PRINT FORM, FILL IN SPACES, MAIL W/CHECK to Anne (see below)

Name (please print)
____________________________________________________________________

Address_____________________________________________________________

Phone (home) _____________________(cell) ______________________________

Email _______________________________________________________________

Your Church _________________________________________________________

Roommate(s) name(s) (roommates must be listed on each other’s registration forms)

I can bring a drum/other musical instrument (just for fun!) _____________________

Please indicate here _____ if you require first-floor accommodation.

I am/am not (circle one) a vegetarian.

Special dietary circumstances? (Example: gluten or lactose intolerant; specific allergies)

_____________________________________________________________________

The Money Part: Retreat Rates and Opportunity

Rates  for food and lodging are what the site charges

Commuter meals include Friday supper, Saturday lunch and supper, Sunday lunch

Resident $140 (includes two nights and 6 meals )           $_________

Commuter $105.00 (includes 4 meals)                              $_________

Registration: $60.00 (our costs)                                            $___60____

My gift to help another woman attend                                 $_________

GRAND TOTAL (add lines above)……………………          $_________

Please make your check payable to:  Joseph Priestley District,
marking in the memo section “W & R Retreat”

*******Payment must be received by September 25th, 2010******

Mail to: Anne Slater, 2753 Morris Road, Ardmore, PA 19003

I will acknowledge receipt of your registration and check via email

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