HOM Workshop for Religious Leaders Registration

Title *

Name *

First

Last

Email *

Phone *

Name of Community Serving/Served *

Current Status *

Active
Retired

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Dietary Preference *

Identify dietary preferences for meals.

Include a second participant in same room? *

Yes
No

Is second participant a non-participation spouse/friend? *

Yes
No

If single registration, are you willing to room with another participant for a price reduction? *

Yes
No

Space is limited. This would be necessary to accommodate more participants when the single rooms sell out. Price reduction = $140. If you are willing, tick YES and select ‘1 person, private room’ ($660) below, and we will reimburse you if it becomes necessary to double up.

Gender *

Female
Male

Info for assigning roommates by gender if/when single rooms sell out.

Second Guest Title *

Second Guest Name *

First

Last

Second Guest Email *

Name of Community Second Guest Serving/Served *

Current Status of Second Guest *

Active
Retired

Second Guest Dietary Preference *

Identify dietary preferences for meals.

Participant Registration *

If 1 friend is joining you, paying separately, both should select the “1 person, additional person TBD” option. Add friend’s name(s) in the comments.

Pay by Credit Card *

Card Number

Expiration

/

Security Code

Comments or Questions

Healing of Memories Workshop for Religious Leaders