Registration Form - Relationship Renewal Couples Weekend Retreat

Date of Retreat: Mar 9-11, 2012 Apr 13-15, 2012 May 4-6, 2012

Her Full Name:

His Full Name:

Please check if address is for both of you:

Address:

City:

Prov:

Country: Zip/Postal Code:

Home Telephone: (please include area and country code)

Please indicate second address below (include all detail as above):

Her Cell Phone: His Cell Phone:

Her Work Phone: His Work Phone:

Her Email: His Email:

How did you hear about this workshop?

Fee per person: $949 Cdn. + 13% tax. Includes all tuition, coaching, two buffet breakfasts, two buffet lunches, snacks and refreshments throughout weekend and two weeks free coaching after the retreat.  Hotel is extra and must be booked separately. Please go back to the main page and scroll down to read about the hotel venues, Grace Cirocco's background and approach and her amazing testimonials.

A deposit of $500 Cdn per person (total $1000) is required to guarantee your reservation as space is limited.

How will you be paying your deposit?

Paypal - (a secure online payment system that takes creditcards and debit)

By Telephone:  Call our office 905-688-0868 Monday - Friday 9am-5:00pm and Retreat Co-ordinator, Leah Taylor will register you over the phone. If you're calling after hours, it's best to fill out the online registration form and pay your deposit by paypal which is the safest internet payment system in the world.

Certified Cheque - (mailing instructions on next page)