2010 Gathering Registration

If you are paying by check, you may use the form below to submit your registration information, and send your check separately by mail to the address provided at the bottom of the form.

If you plan to pay by credit or debit card online, please fill in the additional credit card payment fields below, and submit. You may enter your personal information with confidence, as we use SSL encrypted security for our registration form and shopping cart.

YOUR REGISTRATION DETAILS: (* indicates a required field - please fill in ALL REQUIRED FIELDS)

Name: *

Address: *

City: *

State/Province: *

Zip/Postalcode (at least 5 digits): *

Telephone (xxx-xxx-xxxx): *

Email: *

(We communicate primarily by email. If you have one, please include.)

Birthdate (MM/DD/YYYY):

(IMPORTANT: We need your birthdate for ceremony, please provide.)

Is this your first time?:

yes

How did you learn of CC?:

Do you have special needs?:

yes

If you answered 'yes', above, please describe::

Do you want us to assign a roommate to share a double room?:

yes

If you have a roommate preference, please indicate her name:

(Note: all roommates must request each other.
Please do not name a roommate without confirming with her first.)

How will you be paying for your registration?:

By Check/Money Order
See the bottom of the form for payment mailing address and further instructions.

By Credit/Debit Card
VISA/MC/DISC accepted.

IMPORTANT: Anyone attending a Crones Counsel gathering must sign a waiver of liability. Your reservation cannot be completed until you have agreed to the waiver of liability.

I have read and agree to the Liability Waiver Statement

IF PAYMENT IS BY CHECK OR MONEY ORDER:

Please make your check or money order payable to CRONES COUNSEL, INC. and mail to:

Crones Counsel Registrar c/o Judith Neihart
P.O. Box 9446 Salt Lake City, UT 84109-0446

Phone: 801-466-3923
Email: registrar@cronescounsel.org

Scholarships:

Refunds:

Cancellations up to July 31, 2012 will be given a total refund less a $25.00 processing fee. Cancellations between August 1st and October 1st will be given a total refund less a $50 processing fee. No Refunds for registrations can be given after October 1, 2012.

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The Crones Counsel
info@cronescounsel.org

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