EmailMe Form - Grace Cirocco Womens Take The Step Retreat

Full Name *

First Last

Select A Date *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Cell Phone

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Other Phone

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Primary Email *

Secondary Email

Food Allergies

How did you hear about this workshop?

Occupancy *

Single Occupancy

Double Occupancy

Please Note: Single rooms are not guaranteed but every effort will be made to accommodate you.

If you clicked on "double" room, Grace will assign you a roommate.

Friend's Name

First Last

If you are registering with a friend and would like to room with her, please type her name above.

Deposit of $750 CDN is required to guarantee your reservation. *

Credit Card - We accept MC & VISA. Leave your card #, expiry, & > number on the back on our secure landline (24 hours) 905-688-0868

E-transfer - Please send to grace@gracecirocco.com Security > Question: Grace's favourite flowers: Answer: Tulips

Certified Cheque or Money Order, mailed to Grace Cirocco Inc. 179 > King Street St. Catharines, ON L2R 3J5 Canada

Please click submit to enter the form. Please only click submit once and wait for the confirmation message.

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