Registration Form

A nonrefundable $100.00 deposit is due 3 weeks prior to the workshop. The balance is due when you arrive.

Name:

Address1:

Address2:

City:

State:

Zipcode:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Workshop You Wish
To Register For:

What are you hopingfor in your experience
at this retreat?

Emergency Contact Information:

Contact Name:
Relationship:
Home Phone:
Cell Phone:

Health History:

Date of Birth
Food Allergies:
Dietary Restrictions:
Other Allergies:
Chronic Health Issues:

Please send a nonrefundable, $100.00 deposit for each workshop you've selected.
(Make checks payable to Blooming Valley Retreat)

Blooming Valley Retreat
595 East Buchanan Road
Shelby, MI 49455