Pacific Northwest Dathun - Registration Form

Pacific Northwest Winter Retreat Registration Form
	Option A: Month Retreat (Dathün) Full Retreat: Dec 6, 2008 - Jan 3, 2009 Price: $1150 CAD	Option C: The Roar of the Werma Full Retreat: Dec 20, 2008 - Jan 3, 2009 Price: $750 CAD
	Option B: Dathün Shorter durations: For a shorter duration retreat, choose from the following: Three Weeks : Dec 6 - 27 Three Weeks : Dec 13 - Jan 3 Price: $900 CAD Two Weeks : Dec 6 - 20 Two Weeks : Dec 13 - 27 Two Weeks : Dec 20 - Jan 3 Price: $650 CAD One Week : Dec 6 - 13 One Week : Dec 13 - 20 One Week : Dec 20 - 27 One Week : Dec 27 - Jan 3 Price: $385 CAD	Option D: The Roar of the Werma Shorter durations: For a shorter duration retreat, choose from the following: One Week : Dec 20 - 27 One Week : Dec 27 - Jan 3 Price: $400 CAD
For seniors (at least 60 years of age) and full-time students: 5% discount For registrants who pay in full by October 1, 2008: 5% discount Total:

Personal Information Please Note: Fields marked with * must be completed.
First Name	*
Last Name	*
Address	*

City	*
State/Province
Zip/Postal Code
Country	*
Phone	*
Email
Other Information
Birthdate	*
Gender	Female Male *
Emergency Contact Name	*
Emergency Contact Phone	*
Medical conditions we should know about, including medication Enter None if not applicable	*
Indicate which items you cannot eat.	Soy Products
	Wheat Products
	Dairy Products
	Meat Products
	Mushrooms
	Peanuts
	Citrus
	Nightshade Family (include eggplant, tomato, chili, and potato)
Other Dietary Restrictions
How did you hear about this program
Payment Information We require a deposit of to complete your registration. Final payment is due by November 29th, 2008. Please make cheques, money orders, or bank drafts, in Canadian funds, payable to: 'Vancouver Shambhala Centre' Include the words "PNW Winter Retreat" on your payment; and mail your payment to: Ty Runkle, PNW Winter Retreat Registrar c/o Vancouver Shambhala Centre 3275 Heather Street Vancouver, BC V5Z 3K4 Canada
Refund Policy You may cancel your registration and receive a refund less 10% of the program cost. If you cancel within two weeks of your program start date, you will receive a refund less 25% of the program cost. No refunds are given for cancellations after arrival day.
Please click the button once only.
Please feel free to contact our registrar, Ty Runkle at tyrunkle@telus.net or by calling 604-520-7611 and leave a message.