Printable Registration Form | Women's Recovery Wor

Early Bird Registration $145 August 30th Through September 27th

Registration $155 After September 28th Through October 18th

Scholarship Registration $77.50 August 30th Through October 18th

Full Name

________________________________________________________________________________________________

Address: City, State, Zip

________________________________________________________________________________________________

Phones Email

________________________________________________________________________________________________

Can we email you for further notices and confirmation? Yes_____ No_____

Have you attended before? Yes_____ No_____

What 12 step program(s) have you attended before?

________________________________________________________________________________________________

Your sober/clean date ____________________

Are you elderly and need a bottom bunk? Yes_______ No______

Bottom bunks are first come first serve, and must be requested. If you can take an upper bunk, please do.

If there's room, I'd l ike to share a cabin with:_______________________________________________________

Make checks payable to: Women's Recovery Workshop

Mail to:

Women's Recovery Workshop
C/O Chris Langford
575 Concord Road
Apartment 2101
Jefferson, GA 30549