2006 WINTER RETREAT REGISTRATION
First name:
Last name:
If registering for a married couple, spouse's name:
School (current or alum affiliation):
Your gender:
Street address:
City:
State:
ZIP:
Email:
Do you need a ride? Can you offer one?
How long will you be staying?
What kind of accommodation do you need?
Are you able to sleep in a more noisy environment?
What is your payment amount?
  • Single attender, registering on or before Feb 3 -- $85
  • Married couple, registering on or before Feb 3 -- $160
  • Single attender, registering after Feb 3 -- $95
  • Married couple, registering after Feb 3 -- $180
Enter amount here (no $ sign):
Are you able to donate a little extra ($10, $20 etc) for students who can't afford the full price? If yes, please fill in the amount here:
Emergency contact name:
Emergency contact number:
Health insurance:
Special needs (including allergies, medical conditions, medications, food requirements):
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