Annual Housecleaning Retreat eRegistration

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Electronic Registration for Annual Housecleaning Spiritual Retreat for AA and Al-Anon

First Name *

As you want it to appear on name tag

Middle Initial

(Optional but suggested)

Last Name *

We need you full last name but first initial of your last name will be used on name tag

Street address *

Please include suite or appt#. Confirmation will be mailed to this address.

City *

State *

2 letter initials of State only please, example; FL for Florida

ZIP code *

5 number zip codes only please

Phone number *

Please enter the primary number you use

Email Address *

Initial confirmation will be sent via email

Sobriety Date *

If you do not wish to put a sobriety date, put today's date in the response below

YYYY

Program *

Let us know if you are in AA or Al-Anon or Both

Al-Anon

Double Winner

Gender *

Men with the Men, Women with the Women so we need to know which one you are

Male

Female

Type of room to reserve and payment *

Single rooms are limited, we will notify you if we CANNOT accommodate a single room order.

Double occ. room - Pay via paypal

Double occ. Room - Pay via Zelle

Double occ. room - Send check (must send full payment)

Single occ room - Pay via paypal

Single occ room - Pay via Zelle

Single occ room - Send check (must sent full payment)

Attending Virtual no room needed - Pay via Paypal

Attending Virtual no room needed - Pay via Zelle

Attending Virtual no room needed - Send check

If we create a T-Shirt and offer it as a post retreat mail-to-you item would you be interested?

Yes

Clear selection

Physical issues we should know about

Please check all that apply to you, use addition comments for any other issues

Difficulty walking

Food alergies, please specify in additional comments

Vegetarian

Additional Comments

Example; room with my friend Roger Slusser, I use sleep apnea machine at night, I am allergic to peanuts, etc...

Name of Significant other if attending

We do not allow significant others to room together, yes... even married couples.

Are you over 60 *

Do you snore loudly *

Do you have trouble with Stairs *

Do you smoke/vape *

Are you Covid-19 Vaccinated? Full vaccination is required to attend in-person. Virtual is open to all. *

Yes

Registering for In-Person or Virtual *

In-Person

Virtual

Submit

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