Retreat Registration Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

Please indicate which retreat you are signing up for:

Please indicate the amount you'd like to pay:

If there is anything you'd like to share about your internal process, or other healing or spiritual work you've done, please do so here:

Please let us know about any health issues or physical accommodations you need:

How did you hear about us?

Is there anything else you'd like us to know?

Please click here if you would NOT like to be on our mailing list

how to hold your spot

Please send your payment via Venmo to Jan Birchfield, @Janis-Birchfield.

Thank you!