Brotherhood Retreat Registration: July 12-15, 2012

Please complete this form on your computer. Then print, and mail it to us with your deposit.
Name:
Address:
 
 
Email:
Phone: Alt. Phone:
Year of Birth:    Year of HIV+ diagnosis: 
Dietary Needs: Vegetarian Other: Vegan
Requested roommate: 
Are you able to host an out-of-towner in the New York area for the weekend prior to the retreat?
YES, person(s) for days          NO		 Do you want to be matched with a local host in the New York area for the weekend prior to the retreat if possible?
YES days         NO
Will you be driving to the retreat?
YES      NO      DON'T KNOW
If yes, are you willing to let other participants ride with you?
YES, max. people      NO
Are you a light sleeper?
YES      NO
DON'T KNOW		 Do you snore?
YES      NO
DON'T KNOW
Deposit **
Full Retreat Fee
PRINT THIS PAGE BEFORE CLICKING BELOW!
Single Room * $225.00
PayPal Options:
Contribution to scholarship fund
TOTAL AMOUNT PAID ****
PayPal Registration Options
Mail check or money order in U.S.
funds drawn on a U.S. bank to: 		Brotherhood Retreats
7515 Hannum Avenue
Culver City, CA 90230    U.S.A.
Please list any medical or physical needs that we should know about on the back of this form.
* A limited number of single occupancy rooms will be available on a first-come, first-serve basis. For single occupancy, add a $225 single room fee to the deposit. The fee will be applied to the total cost if a single room should not be available.
** A minimum deposit of $225.00 is required to secure your space. Payment is due in full by June 12, 2012. Deposits are refundable for 30 days after your registration, minus a $50 administration fee. Deposits may be transfered to a person who is not yet registered. No refunds after May 13, 2012.

**** For PayPal payments, please add $15 PER PAYMENT to cover the PayPal fees.

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