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

Home Phone *

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

Work Phone

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

Cell 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. *

By email from your banking institution to grace@gracecirocco.com Security Question: Grace’s favourite flower: Answer: Tulips

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

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

Paypal - (a secure online payment system that takes creditcards and debit)