2005 PANEURHYTHMY REGISTRATION FORM

(If at all possible, please send in your registration by the end of April.)

 
Name: ___________________________________________________________

Address: _________________________________________________________

Phone No: ________________________________________________________

E-Mail Address: ___________________________________________________

 
FOOD PREFERENCES [Meals will be vegetarian, some with fish]
 
Special dietary requirements:
______________________________________________________
______________________________________________________
______________________________________________________

ROOM PREFERENCE [check]                     

Multiple occupancy (3 persons)    [   ]      $ 395
Doubles occupancy (2 persons)   [   ]      $ 480
Single occupancy (1 person)        [   ]      $ 550

 (limited availability)          


 Roommate(s) request: _________________________________________


____________________________________________________________
 
 
THE FEES cover your room and board and contribute toward the expenses of our teachers’

room and board. 

 

Unless already sent in, a $200 DEPOSIT should accompany this form. 

The balance will be collected at the Retreat.

Make check payable to Bob Segbarth and send to him with this registration form:

211 West Floresta Way,

Portola Valley, CA 94028

SCHOLARSHIP FUND:
 
We do not want financial concerns to limit participation. If you wish to make a tax-deductible contribution, please include with your registration to Bob Segbarth a separate check made out to

Paneurhythmy Circle of Joy.”

 
QUESTIONS:
Ardella Nathanael:  (415) 499-8027
Bob Segbarth:   herbnmin@aol.com

 

It would help our administrative arrangements if you would send this in AS SOON AS POSSIBLE.

 

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