Reg Form Must. Feb 2020 - DISCOVERING WHOLENESS-BROUGHT TO YOU BY THE CENTER FOR THE HEALING ARTS & SCIENCES

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First Name *

Last Name *

Email *

Cell Phone *

Room *

Roommate Request *

Food Restrictions *

How Did You Hear About This Retreat? (Be as specific as you can) *

Optional Acupuncture Session - $135 *

Optional Individual Processing Session - $135 *

What Would You Like to Get Out of This Retreat? (Tell us in as much detail as you are willing) *

Additional Information *

Emergency Contact Information

Emergency Contact #1 *

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Phone Number *

Relationship to You *

Emergency Contact #2 *

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Last

Phone Number *

Relationship to You *

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