One-Day Retreat with Louix – Racine, Wisconsin

To register for the retreat click here

Wisconsin Jul 2011 flyer final2 One Day Retreat with Louix Racine, Wisconsin

To register for the retreat online use the registration form below.
To register by mail or fax, please download a printable form by clicking here.

Registration Form

Date:	Sunday, 10 July 2011
Time:	10:00 a.m. - 6:00 p.m. (Registration begins at 9:00 a.m.)
Location:	The DeKoven Center 600-21st, Racine, WI 53403
Cost:	Adult $250.00 (Includes a vegan lunch) Children's rates: Less than 3 years old: Free / Ages 3-11: $40.00 / Ages 12-15: $80.00

As a condition of participation in the Racine One-Day Retreat on 10 July 2011 ("Retreat"), you are required to complete this Registration Form (separate forms must be completed for each adult and each child attending) and mail it to the address below, along with the registration fee of $250.00 per adult ($100 of which constitutes the non-refundable deposit), or you can register online at www.LouixWisconsin.org. Once registered, you will receive a welcome packet along with additional forms to complete, which will be e-mailed (or mailed) to you, including a Liability Waiver, Recording Release, and Medical Information Form, which must be completed as a condition of participation in the Retreat. There will be no refunds after 10 June 2011 for any reason. Refunds may take up to 45 days to be issued.

Yes, please register me for the One-Day Retreat with Louix Dor Dempriey.

First Name: Last Name:

Street Address:

City: State: Zip:

Phone:

Fax:

E-mail:

Please provide your payment information below.

Please charge my credit card the following amount: $

Card Holder First Name: Last Name:

Card Type:

Card Number:

CCV:

Expiration: /

By submitting this form, I do hereby release Louix Dor Dempriey Foundation and its agents and assigns from all liability for any reason and/or circumstances whatsoever arising before, during, and/or after the Retreat, including during participant's travel to and from Retreat, as outlined in any advertising materials and on any and all forms related to this Retreat. I also acknowledge that I understand the terms and conditions under which I am registering for this Retreat, that this form is legally binding, and that I am eighteen years of age or older*. My attendance at this Retreat is not guaranteed until this completed Registration Form, the Recording Release, Liability Waiver, Medical Information Form, and full payment are received by the Louix Dor Dempriey Foundation. I do hereby consent to having my name, voice, image, and likeness recorded and used for commercial purposes.

* Please complete below if participant is a minor (under the age of 18): I am the Parent or Guardian of the minor named above and have the legal authority to execute this release on behalf of the above mentioned minor.

Guardian Name :

For more information, please contact Samantha:
Phone: (888) 288-3735
E-mail: samantha@Louix.org