PLEASE EMAIL TO : info@tipilifestyles.com

OR if you have trouble downloading this form,let us know & we will email it to you:

DATE:_______________

NAME:_________________________________________________________

ADDRESS:______________________________________________________

CITY,STATE, ZIP:________________________________________________

PHONE:_______________________CELLULAR________________________

EMAIL:__________________________________________________________

PERSONAL INFORMATION:

AGE: __________________ GENDER: _____________

ALLERGIES or MEDICAL CONDITIIONS:____________________________

_________________________________________________________________

PHYSICAL LIMITATIONS (if any):__________________________________

_________________________________________________________________

DIETARY RESTRICTIONS:_________________________________________

I EAT ___CHICKEN ___FISH ___BEEF ____ I AM VEGETARIAN

Emergency Contact: _____________________________________________

RESERVATION CHOICES FOR Sept. 9-15, 2012

please choose one:   [Note: Private rooms are in demand, request early]

______Shared Room & Bath                               @ $1495./single.

______Private Room w/ Double bed                  @ $1595./single or  $2990./couple

______Private Room  w/ Queen bed & bath      @ $1695./ single or $3080./couple

Deposit of $300 now to reserve your space, remainder due 35 days prior to Retreat date.

Cancellations after that time, forfeit deposit.

____________________________________________________________________________

I AM REGISTERING FOR THE Sept. 9th, 2010 RETREAT AND ENCLOSING A CHECK FOR: ___________ Deposit. I will remit the balance of ________________ by July 30, 2011.

___________Full Payment

signed: _____________________________

(If you wish to pay by credit card, please call us with your card information.)