utahkrishnas.org - Om Shanti Retreat Registration

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Om-Shanti-Poster-Oct.-20120

Retreat Registration

Select Package: *

Family Name: *

First Name: *

Phone: *

Email Address: *

Street Address: *

City *

State: *

Country: *

Postal (Zip) Code: *

Billing Info: * Same as address above Use the following info:

Name on Credit Card: *

Billing Address (street,city,state, zip)

Credit Card: *

Card Number: *

Expiration Date: (mm/yyyy) *

Security Code: (required for Visa / MC)

Registration Information: Select Your Gender (for housing allocation only) * Male Female

Date of Birth:

Languages Spoken:

Please indicate any medical conditions:

Emergency Contact Name: *

Emergency Contact Relation: *

Emergency Contact Phone: *

Transportation Method: *

Airport Pickup/Dropoff * Yes - 45 Dollar Charge No

Travel Info: (Dates, Times, Flight #, Departure City)

Liability Waiver I Agree - The following digital signatures indicate that participants relieve Krishna Temple from all liabilities in the event of any injury or illness incurred while visiting Om Shanti Retreat.

Digital Signature: (Enter your name & date) *

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