Registration Form

Weekend Retreat with Carol Blotter

October 18-20, 2019

name: _____________________________________________________________________

address: ___________________________________________________________________

city: _____________________________________ state ______  zip: _________

gender: _______

phone: _________________________

email: ______________________________________________

special needs: ______________________________________

dietary restrictions: ________________________________

_____________________________________________________

_____________________________________________________

registration fee:

___ $195  covers the cost of room and board for the retreat

___ $210 covers the cost of room and board as well as helps with the teacher’s travel costs

___ $225  covers room and board, helps with travel costs, and helps us to be able to offer scholarships

___$ Other _____________________________________________________

(50% deposit requested with your registration, the remainder is due by March 29th)

amount enclosed:  $_____________

Please make checks payable to Insight Meditation of Cleveland

Mail form and payment to:

Insight Meditation of Cleveland
 PO Box 113
 Novelty, OH 44072