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White Clay Women’s Retreat – March 6-8, 2015 - Black Rock Retreat Center
“HE Moves, You Move”
Exodus 40:36-37
Name_____________________________________ Date_____________________________
Phone_____________________ E-mail_______________________@___________________
Select your room arrangement (required): Price includes 2 nights & 5 meals
____ 2 people to room (double)
Pay $220 per person
Note: A double may be requested but is not guaranteed, depending on attendance
____ 3-4 people to room (triple-quad)
Pay $199 per person (incl. 2 nights & 5 meals)
____ cabin (bunk beds in separate building; limited beds available) Pay $130 per person
I want to room with (names):
(1)______________________________ (2) ______________________________
 Surprise me! (we’ll assign your roomies)
Personal needs: If you have any allergies that the Committee needs to know about, please let us know
ahead of the Retreat. If you have special dietary needs, please plan to bring any special food that you
require, as Black Rock is not able to cater to special food needs.
 I will need a ride
 I can provide a ride for (#) _____ riders
PAYMENT INFO for 2015 (Read carefully)
A $50 NON-REFUNDABLE DEPOSIT is required at time of signup (you may also pay in full).
FINAL PAYMENT is due no later than Sunday, Feb. 22 ** IMPORTANT: If we do not have your final payment
by Feb. 23, we will contact you.
( Check here if you need an email reminder 7 days ahead of the payment deadline.)
CANCELLATION DEADLINE is also Sunday, Feb. 22. All but the $50 deposit is refundable if you cancel by
Feb. 22. We have to make a firm commitment to Black Rock, so unfortunately, after Feb. 22, the full
amount will still be owed even if you cannot attend, and no refunds can be given. (Solution: find a
replacement and collect the fees from her.)
I have read the payment info & understand the Committee is unable to make exceptions.
 Enclosed is my check #_______ in the amount of $_________ (“Women’s Retreat” in memo)
 Enclosed is my cash payment in the amount of $_________
 Enclosed is $___________ to be used for scholarships. Check # __________ or  cash
Include “Women’s Retreat Scholarship” in the check memo
If you would like to request a scholarship/partial scholarship, please talk to a planning team member.
Anything you can contribute toward the cost is appreciated and allows us to extend scholarship
monies to more women.
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