REGISTRATION – Power Place: Earth Connection & Empowerment

Registration Info

First Name*

Last Name*

Street Address*

City*

State*

Zip*

Phone*

(000) 000-0000

Email Address*

Confirm Email*

Payment Details

Payment Amount*

Name On Card*

Card Type*

Card Number*

Exp Month*

Exp Year*

CVV*

Billing Zip*

Light snacks, water, and prayer tie materials will be provided. Please bring your own lunch with you.

Emergency Contact

We require the name, relationship, and phone number of someone we can contact on your behalf in the
event of an emergency during your participation in this retreat.

Contact Name*

Full Name (First and Last)

Contact Number*

(000) 000-0000

Relationship*

Contact Name

Contact Number

(000) 000-0000

Relationship

Acknowledgement*

Terms • Privacy • Legal

I am 18 or over and agree to Terms & Conditions.

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