Name: __________________________________________________

Age:  18-25 ___   26-35 ___   36-45 ___   46-55 ___   56-65 ___   66-75 ___   76+ ___

Address: ______________________________________________________

Phone Number: ___________________________

Email Address: _______________________________________________

___ Check here if you do not want to receive the Newsletter by email

Roomate(s): ________________________________________________________

Please circle your choice:    Single Room ($425)      Double Room ($300)     Triple Room ($275)

Subsidy Requested:  _____________ (please indicate amount)

Donation: ___________________ (thank you)

Your gracious donation is much appreciated to help us cover all our subsidy requests.

Registration is confirmed upon payment received.  Cheques should be made payable to "Women of Bethany" and may be postdated to October 1st, 2010.  All infants 6 months of age or younger are welcome.  Please let us know if you are bringing an infant. 

Special room requests (please explain if standard room is problematic):

Special dietary needs:

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Please feel free to print out extra copies of this page and invite family and friends!