Annual Housecleaning Retreat eRegistration
Electronic Registration for Annual Housecleaning Spiritual Retreat for AA and Al-Anon
First Name *
As you want it to appear on name tag
Your answer
Middle Initial
(Optional but suggested)
Your answer
Last Name *
We need you full last name but first initial of your last name will be used on name tag
Your answer
Street address *
Please include suite or appt#. Confirmation will be mailed to this address.
Your answer
City *
Your answer
State *
2 letter initials of State only please, example; FL for Florida
Your answer
ZIP code *
5 number zip codes only please
Your answer
Phone number *
Please enter the primary number you use
Your answer
Email Address *
Initial confirmation will be sent via email
Your answer
Sobriety Date *
If you do not wish to put a sobriety date, put today's date in the response below
MM
/
DD
/
YYYY
Program *
Let us know if you are in AA or Al-Anon or Both
Gender *
Men with the Men, Women with the Women so we need to know which one you are
Type of room to reserve and payment *
Single rooms are limited, we will notify you if we CANNOT accommodate a single room order.
Will you be buying a T-shirt? Pre-orders are guaranteed and set aside for you.
Shirts are purchased separately from registration fee. Only pre-paid shirts are reserved. PayPal has options to include shirts or amount can be added to the check sent in. 100% of proceeds from T-shirts go to scholarships.
Physical issues we should know about
Please check all that apply to you, use addition comments for any other issues
Additional Comments
Example; room with my friend Roger Slusser, I use sleep apnea machine at night, I am allergic to peanuts, etc...
Your answer
Name of Signifcat other if attending
We do not allow significant others to room together, yes... even married couples.
Your answer
Do you smoke/vape *
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