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:

Name of Program: Healing the False Self

Presenter: Don Bisson, FMS

Program : #DB-10-1214

Dates: October 12-14, 2012

Please print this registration form, include payment where applicable, and mail to Wisdom House.

Accommodations
___ Commuter	___ Shared Room/Hall bath
___ Private Room/Hall bath	___ Private or Shared Room w/Bath (limited, give second choice)

Meal Options: (Please check one for yourself and friend, if applicable)

__ Standard

___Vegetarian (No meat or fish)

___ Lactose Intolerance

___ Celiac

Payment: ___ Here is my credit Card information

MasterCard, Visa accepted. Add 4% for credit card use.

Credit Card Type:_________________________ Name:__________________________________
Number:___________________________________________ Expiration Date:________________

Deposit (non-refundable) enclosed ____________________

Full payment enclosed _____________________________

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

Checks are payable to Wisdom House

Name:_________________________________________________________________________________

Mailing Address: ________________________________________________________________________

City: ___________________________________

State: __________________

Zip: ______________

Day Phone: ______________________________

Other Phone: ________________________________

E-mail: (Print Clearly Please) : _____________________________________________________________

Roommate's Name: __________________________________________________________________________