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: __________________


Sobriety Date:                ___________

Dietary Allergies:        ___________

Vegetarian:                ___________
                
* Physical Need:        ___________
* Over 60:        ___________
*Do you smoke/vape    Y    /   N
Trouble Climbing Stairs   Y   /   N

Name your significant other if attending
Room assignments will be separate
______________________________

These prices are Pre-paid with registration:

TEE SHIRT: $16         How many? _____

S___ M___ L___ XL ___XXL ___ XXXL___

SWEATSHIRT: $22        How many? _____

S___ M___ L___ XL ___XXL ___ XXXL___

                        Amount
Registration:                _______
T-Shirt:                        _______
Sweatshirt:                _______
Total Enclosed:         _______

     *Proceeds from Tee Shirt & Sweatshirt
 Sales Support Scholarships


Make check payable to Tom Brown

Use your browser print button to print this form, fill out the form,  include check and mail no later then January 15th to:

Tom Brown/Carmen Leon
Annual Housecleaning Retreat
2118 Cortez Ave
Tampa, FL  33629


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