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Wisdom House
Registration Form
229 East Litchfield Road Litchfield, CT 06759
Office: 860-567-3163 Fax: 860-567-3166

www.wisdomhouse.org

 
Registering for: Women's AA/ALANON Retreat
Program : #6000
 
Please print this registration form and include payment where applicable.
Organization or
Contact Name
 

male female
Email Address
Street Address
City
State
Zip Code
Phone
Fax
Accommodations
Requested: (where applicable)
Day Program (No room needed)
  roommate requested:
Room w/Bath
 
Meals:





Deposit (non-refundable) enclosed ____________________
Full payment enclosed _____________________________
 
Enclosed is a donation of $_________________ for the Wisdom Fund for Scholarships
 
Checks are payable to Wisdom House
 
CREDIT CARD PAYMENT - please add 4% to amount due and pay in full.
PLEASE Charge:
Account # ________________________________ Exp Date: ___________