Living Room Retreat Registration Form November 1st-3rd, 2019

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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 *

Nickname of Choice

Email Address *

Home Address *

Best Phone Number to Reach You *

Name(s) and Ages of your Child/Children *

Contact Name, Relationship to you and & Phone Number of a Safe Person for you in Case of Emergency *

Type of Medical Insurance and Insurance ID Number *

My intention in joining this retreat is to: *

The activities that are most exciting to me during this retreat are:

Meditation

Acupuncture

Soaking in the Baths

Being out of the city

Group Circles

Hiking

Group Meals

Please list any allergies you have (including to food and/or medication): *

Please share any physical limitations you may have: *

Accommodation and Fees *

Solar Lodge Shared Room: Three Roommates, shared public restroom $660

Cabin with one roommate and Queen size bed $715

Cabin solo occupancy $875

Cabin Suite for 2-3 people: Two room suite with a Queen Size Bed, Kitchenette and Sofa Bed $890

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. *

Venmo

Check to Natashia Fuksman, 3030 Ashby Avenue, Suite 107, Berkeley, CA 94705

Cash (given in person...coordinated with Natashia)

Required

Payment Options *

Full Payment

Payment in two equal parts, one now and one no later than July 15th, 2019

Payment in three equal parts: one now, one by July 1st and one by Aug 15th (add 10%)

If scholarship is needed, please check this box and email Natashia with our request.

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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