RETREAT OR WORK-SHOP BOOKING FORM​

​PLEASE Print a Copy and FILL OUT COMPLETELY, ONE PER PERSON

PLEASE Print a Copy for yourself and  SUBMIT THE ORIGINAL

NAME & DATE OF RETREAT OR WORK-SHOP_________________________________________________________________________

​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)_________  MAKE OUT TO DICK POWELL

​PAYMENT BY CREDITCARD(amount)______________. You will be sent an Invoice via PAYPAL and able to use the Card of your choice securely.
    

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. ​