RETREAT BOOKING FORM
2019 MINDFULNESS RETREAT AT SAN DAMIANO, Danville, CA
January 14 - 16, 2019
PLEASE Print a Copy and FILL OUT COMPLETELY, ONE PER PERSON
PLEASE Print a Copy for yourself and SUBMIT THE ORIGINAL
CITY____________________________________ STATE________________________ ZIP___________________
DATE OF BIRTH_________________________________ SEX________MALE______ FEMALE
OCCUPATION (current or prior)____________________________________________________________________
MOBILE PHONE___________________________________ OTHER PHONE______________________________
ANY SPECIAL DIETARY REQUIREMENTS________________________________________________________________________________
ANY OTHER SPECIAL CONSIDERATIONS________________________________________________________________________________
PAYMENT BY CHECK(amount)_________ or CREDIT CARD(amount)___________
To book include a deposit of $100 per person, add $40 deposit if staying over, $140 Total. To pay in full pay $289 per person, add $130 if staying over, $419 total.
If by check, make it out to Dick Powell and include it with the completed Booking Form. If by Credit Card, after we receive your Booking Form, you will receive an Invoice via Email from PayPal with a Link to click which will take you to a secure payment site where you can enter your card information and submit. We will be notified when the payment is in our account, and notify you that your booking is complete.
Submit to: Dick Powell, 2956 Tice Creek Drive #4, Walnut Creek, CA 94595
Mail or drop in my door mail slot.
Questions: 925-238-6366 or DickPowell53@aol.com www.mindfullivingclub.org.