Register By Mail

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Register at least one month prior to the event, if possible.  Please print clearly and use the same name on all subsequent  correspondence. If we do not receive two weeks notice of cancellation, your deposit cannot be refunded.

First name_____________________________________________________________

Last name_____________________________________________________________

Address   _____________________________________________________________

City, State & Zip________________________________________________________

Home Phone ________________________  Work Phone  __________________________

Cell Phone  ________________________  E-mail  _______________________________________           

[] Female     [] Male       Roommate request (all double rooms) _______________________________

Event______________________________________         Date________________________

I am paying by check:  Amount enclosed $_____________If you are paying by check send 1/2 of the total amount as a deposit.  Please round the amount to the nearest dollar.

Visa, Mastercard, Discover:  Amount of payment $_________ (must be full amount if paying by credit card)

Card no.______________________________  Exp. date ____________

Signature_______________________________________________________________

For Canadian checks please indicate “US funds” next to the dollar and word amount.

Mail to:  Kirkridge Retreat Center, 2495 Fox Gap Road, Bangor, PA 18013   PHONE 610-588-1793  FAX (610) 588-8510.