Valentine’s Day Couples Dinner & Mini Retreat

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1 Welcome

2 Price

3 People in your group

Guest 1		First Name* Last Name* Email* Gender* Please specify dinner preference*
Guest 1		First Name* Last Name* Email* Gender* Please specify dinner preference*

4 Participant Information

Phone *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Gender *
Please specify dinner preference *
Do you have any food allergies or dietary needs?
Any other allergies?
Requested Table-mate	Please let us know if there is someone you'd like to be seated with.
Emergency Contact Name and Phone Number *
Medical or Mobility Notes	Enter "none" if you have no issues
Comments or Special Needs
How did you hear about us?
Email newsletter	Please send me the email newsletter
Car Make / Model / Color
Refund and Cancellation Policy *	I have read and agree to the cancellation policy terms and authorize Mary & Joseph Retreat Center to charge my credit card to secure my booking. Please process my payment to confirm my booking. Full and 1/2 Day Retreats/Events: $25 cancellation fee, or the cost of the retreat, whichever is less, will be charged per person for cancellations made 5 or more days prior to the start of the retreat. No refunds given for cancellations made less than 5 days prior to the start of the retreat. Overnight Retreats: $75 cancellation fee will be charged per person for cancellations made 5 or more days prior to the start of the retreat. No refunds given for cancellations made less than 5 days prior to the start of the retreat.

5 Donate

6 Security Check

7 Payment

	By submitting payment, you authorize Mary & Joseph Retreat Center to send instructions to the financial institution that issued your card to take payments from your card account in accordance with the terms of Mary & Joseph Retreat Center's agreement with you.