2021 Women's Retreat Registration Form

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Age *

Are you coming with a friend? Do you have a cottage/room type request?

How did you hear about us? *

Do you have any dietary needs we should be made aware of? *

Would you be interested in learning more about a painting workshop? *

Yes

No

Would you be interested in more of an adventure based experience? Paddle boarding excursion on Great Averill, moderate to difficult hike, mountain bike adventure.... *

Yes

No

Would you like to sign up for yoga Saturday and or Sunday morning? *

Yes

No

Would you like to sign up for a massage? (1hr - $95) *

Yes

No

Would you be interested in participating in an extra workshop? ie: fiber workshop, basket weaving, fly fishing... (additional charge to cover materials, license) *

Yes

No

Deposit Information: A $150 deposit is required to hold your spot (Total cost $439.00). The deposit may be paid via credit card, or check. However, we would prefer the remaining balance be paid via check. Please select how you would like to pay your deposit: *

Credit Card

Check

Please mail checks to: Quimby Country, 1127 Forest Lake Rd, Averill, VT 05901

Credit Card Number (We accept Visa, Mastercard and Discover)

Expiration Date (Month and year)

CVV number (the 3-4 digit number on the back of your credit card)

2021 Women’s Retreat Registration Form