| Reflections and Revelations - The Retreat |
Geneen Roth Workshops FAX/Mail Registration
Form
You can view this form without obligation to
submit payment! |
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Please select the Reflections and Revelations Retreat you would like to attend:
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Waiting List Only
Fill out and submit this form to secure your place on the Wait List for the October 2010 retreat with Geneen Roth. You will receive confirmation of your Wait List registration by email from Judy Ross, Retreat Manager.
If a place opens for you at the retreat, you will be notified by email and/or phone. Once you accept a spot, we will require payment of a deposit of $595 to secure your registration. Payment may be made by credit card (Visa, MasterCard, American Express or Discover) or by personal check. Arrangements for payment will be made at the time of acceptance.
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Personal Information * Indicates
required information |
| First Name *
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| Last Name *
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| Billing Address *
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| City *
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State/Province*
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| Zip/Postal Code *
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Country
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| Phone (evening)
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Phone (day)
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| FAX
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| Date of Birth
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| Email Address *
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| Profession
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How did you hear about the retreat? *
Workshop
If you selected workshop - which workshop?
Book
Friend or Family Member
Therapist
Magazine
If you selected magazine - which magazine?
The Oprah Winfrey Show
Other
If you selected other - please specify where.
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| If you received a brochure in the
mail, please enter the P.R.code here
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Reflections
and Revelations Retreat
WorkshopFees/Room Options
All fees include tuition, lodging, and meals.
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Indicate Preferred Room Option
October Retreat Room Options
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| Please indicate how much advance notice you will require to consider and accept a space at the October Retreat:
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Registration & Cancellation Policies
Note: Only signed registrations will be accepted.
Registration Payment Policy:
- $595 minimum down payment ($350 non-refundable/non-transferable) due upon registration.
- Payment by accepted credit cards or check (made payable to "Reflections & Revelations").
- Balance of retreat fees are due 12 weeks before the first day of the retreat. If paying by credit card, any balance due on that date will be charged to credit card on file.
- If using a payment plan, payments by credit card or check must be made on specified plan dates.
Cancellation Policy:
- Cancellations must be requested in writing to "Reflections & Revelations" (email, fax, or USPS).
- Cancellations received 8 weeks or more prior to the first day of the retreat: You will receive a full refund less a $350 non-refundable/non-transferable administration fee.
- Cancellations received between 8-4 weeks prior to the first day of the retreat: You will receive a 50% credit of the registration fee to be transferred to the next scheduled Reflections & Revelations Retreat. This credit is available only if your cancelled space is filled with another registration prior to the start of the retreat. The credit is null and void if not used at the specified retreat.
- Cancellations received less than 4 weeks in advance of the first day of the retreat: No refunds, transfers or credits will be given for any reason.
I hereby confirm that I have read and understand the Registration & Cancellation Policies and agree to these terms. I understand that these policies apply to this and future retreat registrations, unless revised by Geneen Roth & Associates, Inc.
Signature _________________________________ Date ____________
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| I
prefer to return to the Geneen Roth site now! |
Judy Ross, Retreat Manager
Geneen Roth & Associates, Inc.
13060 Taylorstown Road
Lovettsville VA 20132
Voice: 540-822-4539
Fax: 703-852-3956
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