Wisdom House: Registration Form

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

Contact Name

male female

Email Address

Street Address

City

State

Zip Code

Phone

Fax

Accommodations
Requested: (where applicable)

Commuter

Shared Room

–– roommate requested: yes no

Shared Room w/Bath (add $7.50 per night)

–– roommate requested: yes no

Private Room (add $20 per night)

Private Room w/Bath (add $35 per night)

Meals:

Standard
Vegetarian (no meat or fish)
Lactose Intolerant
Celiac

Deposit (non-refundable) enclosed ____________________

Full payment enclosed _____________________________

Enclosed is a donation of $_________________ for the Wisdom Fund for Scholarships