2011 JEWEL HEART SUMMER RETREAT REGISTRATION Tibetan Buddhist Comprehensive Guide for Today’s Spiritual Traveler Thursday, August 25 – Sunday, September 4 Please complete entire form. Return or send with $150.00 non-refundable deposit by July 22, 2011 Mail to: Jewel Heart, 1129 Oak Valley Drive, Ann Arbor, MI 48108 fax: 734-994-5577 Email: email@example.com or call 734 994 3387 x 223. Name(s):______________________________________________________________________ Address:______________________________________________________________________ City____________________________________State__________Zip:_____________________ Phone(s):_____________________________________________________________________ Email:_________________________________________________________________________ I am a member of Jewel Heart Yes No I would like to become a Jewel Heart member and enjoy the retreat discount. Yes If yes, contact firstname.lastname@example.org Not at this time Members: $450 Non-members: $550 Tuition ($450 or $550) $________________________________ Donation to Scholarship Fund: $________________________________ Add $50 for registration after July 22: $________________________________ Total: $________________________________ Less Deposit Included: $________________________________ Balance Due at Retreat: $________________________________ Check (payable to JEWEL HEART) Cash Credit Card Card# ___________________________________________Exp.___________________ Mastercard Visa American Express Discover Signature ___________________________________________________________________ Deposit is non-refundable. Cancellation fees are donated to the scholarship fund. _________________________________________________________________________________________ Describe any health concerns or physical disabilities ________________________________________________________ ___________________________________________________________________________________________________________ For sangha lodging coordination - Contact email@example.com. Please contact no later than July 22. Spaces are limited, please request/respond early. I would like to stay in a Sangha member's home (please describe any allergies or special needs and whether or not you will have a car) _______________________________________________________________________ I have room at my home for retreat guests (please describe your proximity to JH and the available space- i.e. futon in den or spare room with twin beds, and if you have pets, etc._________________________________________________________________ _______________________________________________________________________________________________________________________ Deposit is non-refundable. Cancellation fees are donated to the scholarship fund. All gifts to the Scholarship Fund make a difference during this time of limited resources. Thank you! If you need financial assistance, please contact firstname.lastname@example.org.