EmailMe Form - The Grace Fix Couples Retreat REGISTRATION FORM

Retreat Date *

MM / DD / YYYY

Partner 1

Full Name *

First Last

Email Address *

This email address will receive the confirmation notice as well as any follow up instructions.

Telephone *

### - ### - ####

Partner 2

Full Name *

First Last

Email Address

Telephone

### - ### - ####

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Tax Receipt

Please provide the details below for your tax receipt.

Name for Receipt

First Last

Business Name

Food Allergies

Staying at the White Oaks? *

YES

NO

How did you hear about us? *

A deposit of $500 CDN per person (total $1000) is required to guarantee your reservation. *

I will pay by Credit Card - We accept MC & VISA. Leave your credit card #, name on the card, expiry, & security # on our secure landline (24 hours) 905-688-0868

I will pay by E-transfer - Please send to grace@gracecirocco.com Fast & easy, your amount will be auto-deposited.

Please Note: If paying by credit card, there will be a $50 flat fee added to your amount.