Retreat Registration: Please complete, print and mail this form with your deposit.July 19-21, 2019, Stroudsburg, PA

Name:
Address:
 
 
Email:
Phone: Alt. Phone:
Year of Birth:     
HIV+      HIV-      Don't know/ Prefer not to say | Year of HIV+ diagnosis: 
Dietary Needs: Vegetarian Other: Vegan (Add $35.00)
Requested roommate: 
What is your sexual orientation?
GAY      STRAIGHT      BI Prefer not to say
 
Are you a light sleeper?
YES      NO
DON'T KNOW		 Do you snore?
YES      NO
DON'T KNOW
Deposit **
Triple room ***
Full Retreat Fee
Single Room * $200.00
PayPal Registration Options
Vegan Meals $25.00
PRINT THIS PAGE BEFORE CLICKING BELOW!
Contribution to scholarship fund
TOTAL AMOUNT PAID ****
October 26-28, 2018
Dietary Needs
Do you snore?
Travel needs
Additional notes:
Mobile phone number:
 Mail check or money order in U.S.
funds drawn on a U.S. bank to: 		Brotherhood Retreats
10925 Blix St., Suite 308
North Hollywood, CA 91602    U.S.A.
 
**** Deposits are refundable for 30 days minus a $50 administrative fee. The name on a registration can be changed at any time. No refunds within 60 days of the start of the retreat. Single rooms are available on a first-come, first serve basis and are not guaranteed.
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