RETREAT BOOKING FORM

2018 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.


NAME___________________________________________________________________________________________________________________

ADDRESS________________________________________________________________________________________________________________


CITY____________________________________ STATE________________________  ZIP___________________


COUNTRY_______________________________________


DATE OF BIRTH_________________________________ SEX________MALE______ FEMALE


OCCUPATION (current or prior)____________________________________________________________________


MOBILE PHONE___________________________________ OTHER PHONE______________________________


EMAIL___________________________________________


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.