Annual Housecleaning Retreat
Please print name clearly and
Return with deposit or full payment
(Circle appropriately)
Male / Female AA / Al-Anon
Name: ______________________________
Address: ____________________________
City, ST, Zip: ________________________
Phone: __________________
Email:____________________________________________
Sobriety/Serenity Date: ___________
Physical Needs: ___________
Diatary Needs: ___________
(Circle appropriately)
* Over 60: Y / N Trouble Climbing Stairs Y / N
Do you snore Y / N *Do you smoke/vape Y / N
Covid-19 Vaccinated : Y / N (required for in-person attendance)
Name your significant other if attending
Room assignments will be separate
______________________________
Single Room Y / N Double Room Y / N (Circle 1 only)
Donations for Scholarships are Welcome!
(Circle 1 or both) Amount
T-shirt or Sweatshirt _______ Size _______
Registration: _______
Donation: _______
Total Enclosed: _______
God Bless You and Keep You Until We Meet Again