Conference Registration Form with Payment

RESTORE YOUR INNER GLOW BEACH RETREAT

PLEASE RESERVE YOUR ROOM BY THOROUGHLY FILLING OUT THE BELOW FORM. A $350 NONREFUNDABLE DEPOSIT IS REQUIRED TO HOLD YOUR RESERVATION. Once you fill out all required information an INVOICE will be emailed. (be sure to add rose@rosebruceyoga.com to your contacts). **If you have several people in your party and require separate invoices, please supply those additional names and emails below.** CHECKS OR CASH ARE ENCOURAGED but for your convenience you have the option to pay via debit or credit. ***NOTE: There will be a 3% MARKUP FEE for credit/debit card payments***
Full Name*

First NameLast Name
Phone Number*
E-mail*

Confirmation Emailexample@example.com
Number of people attending including yourself. PLEASE INCLUDE all participant emails if separate invoices are needed.*
NAME OF ADDITIONAL PERSON 1
E-mail additional 1
example@example.com
NAME OF ADDITIONAL PERSON 2
E-mail additional 2
example@example.com
NAME OF ADDITIONAL PERSON 3
E-mail additional 3
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PLEASE NOTE ANY FOOD ALLERGIES OR DIETARY REQUIREMENTS HERE FOR EACH PARTICIPANT
PLEASE SELECT ROOM & OCCUPANCY ~ AN INVOICE WILL BE FORWARDED TO YOUR EMAIL(s).*

4TH FLOOR DOUBLE BED MAIN SUITESINGLE OCCUPANCY $2500DOUBLE OCCUPANCY $2200 ppTRIPLE OCCUPANCY $2000 ppQUADRUPLE OCCUPANCY $1800 pp_______________________________________________________________________4TH FLOOR DOUBLE BED SHARED SUITE ~ ALCOVESINGLE OCCUPANCY $2000DOUBLE OCCUPANCY $1700 pp_______________________________________________________________________3RD FLOOR MASTER KING SUITE ~ OCEAN FRONTSINGLE OCCUPANCY $2400DOUBLE OCCUPANCY $2100 ppTRIPLE OCCUPANCY $1900 pp_______________________________________________________________________3RD FLOOR QUEEN ~ OCEAN FRONTSINGLE OCCUPANCY $2200DOUBLE OCCUPANCY $1900 ppTRIPLE OCCUPANCY $1700 pp_______________________________________________________________________GROUND LEVEL QUEEN BED PRIVATE ROOMSINGLE OCCUPANCY $1700DOUBLE OCCUPANCY $1400 pp_______________________________________________________________________2ND FLOOR QUEEN WALLBED/LIVING ROOM/ NOT PRIVATESINGLE OCCUPANCY $1500
QUESTION(s)?
CHOOSE A SIZE FOR YOUR SOUVENIR YOGA TOP*

SMALLMEDIUMLARGEX LARGE
I WOULD LIKE TO PAY BY*

CHECKCASHDEBIT/CREDIT CARD
Enter the message as it's shown*
Should be Empty:

RESTORE YOUR INNER GLOW BEACH RETREAT