Bereavement Retreat Registration

Registration Form

* Indicates required field

I am registering for the following retreat... *

Programming begins Thursday evening at 5:00pm. Check-In is available beginning at 12:00 noon on Thursday to allow time to settle in. After the Retreat ends, an additional night's stay is available for time to reflect and relax. Please let us know if you would be interested in an additional night. *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

T-Shirt size *

Do you have any dietary restrictions? *

Are there any medical needs we should know about? *

Name of Child Lost to Illness *

Child's Illness *

Date of Loss *

Age of Child *

Daughter or Son *

The Still Place, Inc. is a North Carolina registered 501(c)3 nonprofit organization
registered for solicitation in NC, FL and GA
Financial information about this organization and a copy of its license are available from the State Solicitation Licensing Branch at 919-814-5400. The license is not an endorsement by the State.
FLORIDA SOLICITATION OF CONTRIBUTIONS ACT: LICENSE #CH57163:
A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling toll-free within the State of Florida. Registration does not imply endorsement, approval, or recommendation by the State of Florida.
Florida Division of Consumer Services
1-800-HELP-FLA (435-7352) www.FloridaConsumerHelp.com

Registration Form

Mailing Address: PO Box 31 Hayesville, NC 28904