Name as it appears on Credit Card:

Billing Address of Credit Card:

City:

State (Region):

Zip (PLZ):

Country of Credit Card :

Type of Card:
VISA Master Card BANK WIRE

Credit Card Number:

Expiration Date (Month / Year):

Security Code:

Your EMAIL address:


Your Phone number:

Name of Person attending Retreat:

I am interested in attending this Retreat.
Choose One August 16-19, 2012 4days/3nights August 23-26,2012 August 30-September 3, 2012 5days/4nights September 9-14, 2012 6days/5nights September 16-21, 2012 6days/5nights September 27-30, 2012 4days/3nights October 4-7, 2012 4days/3nights October 14-19, 2012 6days/5nights October 21-25, 2012 5days/4nights October 27 - November 1, 2012 6 days/5nights

Retreat Program with Accommodations:
$ 90.00 per night for a Single Room with shared bathroom $135.00 per night for a Double room with shared bathroom $ 125.00 per night for a Single Room with private bathroom $ 170.00 per night for a Double room with private bathroom

I want a single room:
Yes No

With this registration application I am paying: Choose One $110.00 Deposit non-refundable OTHER DONATION

Participant Agreement CONTACT US: Ruth Davis, Director Simple Peace - Retreats and Silent Stay, 3570 Cantelow Road, Vacaville, California 95688 USA Tel 1.707.474.4833 Ruth@SilentStay.com DEPOSIT: Only the non-refundable deposit of $125.00 per person is necessary to reserve your space. This holds your space and will be deducted from your room charges at the end of the retreat. If for some reason the retreat were to be canceled this amount would be fully refunded within 30 days minus any bank charges. CANCELLATIONS Please email us at if for any reason you need to cancel. Your non-refundable deposit can be credited to another retreat with us in the future if canceled one month before the start date of the retreat. Any cancellations within one month of the retreat are non-refundable. CREDIT CARD CHARGES: Your non-refundable deposit of $ 125.00 will be charged to the credit card you submitted on this Registration form. Charges will appear as Spring Grove, Inc our California non-profit corporation. RETREAT PROGRAM: The retreat program of morning and evening meditation, meditative movement, private retreat guidance is included in the pricing for the accommodations. ACCOMMODATIONS: We reserve the right to adjust rates prior to the retreat. You are responsible to pay for the accommodations at the end of your stay. WHAT TO BRING:Please prepare for all types of weather. We recommend you bring a sweater, warm jacket or coat, socks, sturdy, comfortable shoes for walking, casual clothing for meals, meditation and movement. CHANGES IN ITINERARY: We reserve the right to make any changes to the proposed schedule, that may become necessary in the best interest of the operation of the Retreat, with or without advance notice. ROOMMATES: If any Retreat Participant wants to pay for the Retreat at the shared-room price, yet does not have a specific roommate, we will attempt to match that Retreat Participant with a roommate. However, we cannot guarantee that a roommate will be found. If no roommate is found, then the single room fee must be paid by the Retreat Participant. MASSAGE: Restorative massage and Ayurvedic Body treatments (upon availability). One hour treatments cost $75.00 and are to be paid upon service. Please let us know at the time of your reservation if you would like this service as that will help with availability but, is not a guarantee of service. HEALTH: Any prospective Retreat Participant with a disability, preexisting medical condition, medical history requiring special attention or treatment, or with a history of mental illness and / or are taking medicine for psychiatric illness must advise Simple Peace - Retreats and Silent Stays at time of booking. A prospective Participant is advised to consult with a medical specialist prior to reserving space in the Retreat. People who are unable to travel alone or who would require special assistance or handling must be accompanied by a companion who will provide the required assistance. Simple Peace Retreats and Silent Stays is not responsible for Retreat Participants' health problems during or after the Retreat. INSURANCE: All participants in the Retreat are advised to get travel, medical, accident, cancellation, and baggage insurance independently. Simple Peace Retreats and Silent Stays carries no insurance whatsoever for the Retreat Participants. WAIVER: By signing this Retreat Participant Agreement, the participant releases and agrees to hold harmless, Simple Peace Retreats and Silent Stays and or it's representatives from all responsibility and liability.

I have read and agree to the Participant Agreement Yes No

I would like to have a therapeutic massage during my stay, if available. I understand there would be an additional cost of $75 Choose One Yes, please No, thank you

Additional Message or Arrival & Departure Dates: