if registered by february 5, 2018, $10 late fee after...

Women’s  Retreat  RMR  Church  of  God  P  O  Box  631010  Littleton,  CO    80163  

Application To Register (Please complete, print clearly or type, choose roommates and include your deposit) NAME _______________________________________________________________________ FIRST MIDDLE LAST ADDRESS ____________________________________________________________________

CITY: __________________________ STATE: _____________ ZIP: __________________ PHONE: HOME _________________________ CELL: _____________________________ EMAIL: ______________________________________________________________________

(confirmations sent by email)

Contact Church _________________________ Group Leader___________________________ Handicaps or health/dietary restrictions _____________________________________________ Fee: (select one) If registered by February 5, 2018, $10 late fee after February 5th.

q Four per room $110 q Three per room $130 q Two per room $170 q Private room $275 q Commuter – no meals $ 30 q Commuter- Friday Dinner Only $ 60 A Non-refundable $50 deposit is due with your registration. This deposit reserves your space. q For an Additional cost of $10 per day, please add to my registration these Full Breakfast Buffet coupons for Rustler’s Cafe for : q FRIDAY q SATURDAY

Make Checks Payable to RMRCOG q Payment Amount Enclosed $ ________________ Check # ________________ q Please charge my Visa / Master Card credit card $____________ plus $5.00 processing Fee Total amount charged $__________________ Name on Card: _______________________________________ q Visa q Mastercard Credit Card #: ________________________ CVC #: (3 or 4 digit Security #) ____________ Exp. Date: _____________________ Billing Zip Code: ________________

Mail registration and deposit to: OR Email to WDdirector@comcast.net if paying by credit card.

Roommate  Request  1.          ________________________  

2.          ________________________  

3.          ________________________    

**    No  more  than  4  people  to  a  room    

OFFICE  USE  ONLY    

Date  Rec’d:          _____________  Fee:                                    _____________  Payment  Amt:  ____________  Check  #:                      ____________