Registration Form - Relationship Renewal Couples Weekend Retreat

Date of Retreat: Aug 6-8, 2010 Sept 17-19, 2010 Oct 15-17, 2010 Nov 19-21, 2010

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 per Couple ($250/each) 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)

Leaving Credit Card number on our secure answering machine  905-688-0868  Press Option 2.

Cheque - (mailing instructions on next page)