if registered by february 5, 2018, $10 late fee after...
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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 [email protected] 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 #: ____________