Summer Solstice Healing Retreat 2007 Registration Form

Summer Solstice Healing Retreat 2007 Registration Form
This form must be complete. Incomplete forms will be returned and you will lose your priority in the registration process.
Please remember that we limit attendance to SSHR and that we will likely fill up. We do not allow anyone to enter at the gate if
they have not pre-registered. We will not have room for “walk-ins” or late registrations. Please do not assume you can attend
without registering, or that you are registered without receiving a confirmation letter. Return your registration as early as
possible. We fill all registrations on a first come, first serve basis. Thank you! We look forward to seeing you at this year’s event!
REGISTRATION INFORMATION
First & Last Name of person registering: __________________________________________________ Gender (please circle): M or F
Mailing Address: _____________________________________ City: ____________________________State: ___ Zip:________
Phone (daytime): ________________________ (evening) _________________________ Email: _____________________________
Please list the first and last names of all the other adults in your party (18 and over):
1) __________________________________________ M or F 3) ________________________________________ M or F
2) __________________________________________ M or F 4) ________________________________________ M or F
Please list names of teens and children under 18 (2 per adult max, see letter):
1) ______________________________________ age: _______ 3) __________________________________ age: _______
2) ______________________________________ age: _______ 4) __________________________________ age: _______
REGISTRATION FEES:
Participant Rate Calculation
Adults (18 and over) $101 - 300* _____# adults x $______ (sliding scale) = $_____
Teens (11 – 17) $50 - 150* _____# teens x $______ per teen = $_____
Children (5 – 10) $35 - 100* _____# children x $_____ per child = $_____
Toddlers (0 – 4) FREE! _____# toddlers = FREE
*Indicates a sliding scale.
For those who can afford
to pay on the higher end
please note: you aid in
keeping this event
affordable for others.
TOTALS:
# of PEOPLE _____ TOTAL PAYMENT: $_______
Please circle
all nights
you are
staying:
Thu, Jun 21
Fri, Jun 22
Sat, Jun 23
Note change
of days for
2007 Thu-Sun
Total Payment Enclosed: $_____________ (we prefer checks, please!) We accept check, money orders, Visa or MC only.
Cardholder’s Name: _____________________________Card # _______________________ Exp.: ______
**The ENTIRE registration fee is due with this registration form to hold your space. All payments are non-refundable. If you need to
cancel, you may transfer your reservation to another party (with advanced notice to us). Credit vouchers are no longer available for
cancellations.
ACCOMMODATIONS Indicate your top two preferences by number:
____ Will be camping in own tent (NO OPEN FLAMES PLEASE!)
____ Need to be camping in a live-in rig that is _____ feet long (must be less than 18’). *Limited to the first 10.
(No car sleeping)
____ Need a space in a platform tent (if unable to bring camping gear). _______# of adults _______# of children
____ Need a space in a cabin*. *Note: You must have one of the specified reasons for needing a cabin AND be
willing to share the cabin with others if you are coming alone. Please check the appropriate selections below
demonstrating your need for a cabin:
_____ # of children under age 5 ___Alter-abled ___ Elderly ___Wheelchair Access ___Medical
____ Other (please describe):______________________________________________________________
Please check, if applicable: _____ I am bringing an extra tent or teepee for use by someone else at the gathering.
We will do our best to meet all requirements, but the size of this gathering can be challenging. Your understanding and
flexibility are greatly appreciated and will ensure a healing time for all.
- Continued on Back -

MEALS
Special Diet Request. Please insert the number of people for whom you are requesting “special diet” needs:
I am requesting _______ special diets (a special diet meal item is made without wheat, egg, and dairy).
CARPOOL INFORMATION Please carpool if possible, especially from Portland, Eugene, and Seattle.
*Please note: by requesting or offering carpooling, you are authorizing us to give out your first name and phone number to other
carpooling participants in your area. Please check appropriate selections:
____ I NEED a ride for ________# of people_____
I can OFFER a ride for ________# of people.
Confirmation Letter: We would prefer to send your confirmation via email. If you require a mailed letter, please check this box:
We promise to not sell or give out your email address to anybody.
Mailing List: If you would like to be removed from the Summer Solstice mailing database, please send us an email at
sshr@breitenbush.com to let us know. You may also send a letter to the address below.
Registration Checklist: Did you remember to . . .
___ Include your total payment with this form?
___ Circle all nights you intend to stay?
___ Ensure that this form is complete?
___ Carpool if possible, limited parking!
THANK YOU AND BLESSINGS! WE WILL SEND A CONFIRMATION LETTER ONCE YOUR SPOT IS CONFIRMED!
Mail entire registration form and full payment to:
FOR OFFICE USE ONLY
SUMMER SOLSTICE HEALING RETREAT Payment Receipt # Date/Initial
Breitenbush Hot Springs
P.O. Box 578
Detroit, OR 97342
Space for Notes
WORK EXCHANGE OPPORTUNITY: Breitenbush offers the opportunity to a few people each year to come two
days early in exchange for volunteer work time in the kitchen or with clearing arts (housekeeping). You would be asked
to perform six hours of volunteer labor on each of the two days prior to the event. The work is labor intensive and is not
suitable for people with physical limitations. You would need to stay in your own tent. First priority is given to previous
participants. Since there are only a few spots, you will only be contacted if needed. If you are not contacted, this means
that the need has already been filled. Thank you!
I am interested in volunteering in the kitchen for two days prior to the event.
I am interested in volunteering with clearing arts for two days prior to the event.
Name: __________________________________________ Daytime phone # (
) _________________
Email ________________________________