Camp Blanding Retreat – Registration Form

Camp Blanding Retreat – Registration Form PLEASE PRINT

Please make checks payable to: Olde Green Cupboard Designs 4861 Blackwood Forest Dr., Jacksonville, FL 32257

904-742-1100

[email protected]

____ July 25 - 27, 2014 - $50.00 ____ September 26 - 28, 2014 - $50.00

Last Name:

First Name:

Address:

City, State, Zip:

Home Phone:

Cell Phone:

Email address:

Do you have any food allergies?

Medical Issue?

____________________________________________________________________________________________ Emergency Contact Name:

Phone:

Relationship:

All fees paid/deposited to/with Olde Green Cupboard Designs are non-refundable 21 days prior to the first day of the retreat. Attendee agrees to hold harmless Camp Blanding Joint Training Center, Gloria Parsons/and/or Olde Green Cupboard Designs for any damages, losses, or injuries that may occur while traveling to and from the retreat or during the event.

Cash

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Check #

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Sale Room

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Email add

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Other ______________