Living Room Retreat Registration Form November 1st-3rd, 2019
Living Room for Mothers is going on retreat November 1st, 2nd & 3rd of 2019! Join us by filling out this Registration Form and pressing send at the bottom. Then, please send payment via Venmo, check or dropping off cash to secure your spot and desired accommodation. I can't wait to be at Wilbur with you and our our very lovely community of women!
First and Last Name *
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Nickname of Choice
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Email Address *
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Home Address *
Your answer
Best Phone Number to Reach You *
Your answer
Name(s) and Ages of your Child/Children *
Your answer
Contact Name, Relationship to you and & Phone Number of a Safe Person for you in Case of Emergency *
Your answer
Type of Medical Insurance and Insurance ID Number *
Your answer
My intention in joining this retreat is to: *
Your answer
The activities that are most exciting to me during this retreat are:
Please list any allergies you have (including to food and/or medication): *
Your answer
Please share any physical limitations you may have: *
Your answer
Accommodation and Fees *
I understand that this is the first step to registering. I will pay via Venmo (natashiamft@gmail.com), Check or Cash to ensure my space for the retreat. Below I have indicated my planned payment method. *
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Payment Options *
In an effort towards equity and accessibility, Living Room is offering scholarships for this retreat. This increases diversity for all of us and is a way of actively making a difference to your experience and that of others. If you would like to contribute towards a scholarship fund, please indicate here that you are interested and the amount you will contribute upon payment for the retreat. Please note any additional funds remaining will be donated to the Women's Therapy Center of Berkeley.
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