EmailMe Form - Grace Cirocco Womens Take The Step Retreat

Select A Date *

Full Name *

First Last

Address *

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

Cell Phone

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

Other Phone

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

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. *

Cheque - Certified Cheque or Money Order, mailed to 179 King Street St. Catharines, ON L2R 3J5 Canada

E transfer is available. Please call our office at 905-688-0868 for Security Question and Answer.

By Telephone: 905-688-0868 (Leave your credit card number on our secure line, 24 hours)

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

Date Time

MM / DD / YYYY