Fall Mountain Retreat
Please print name clearly and
Return with deposit or full payment

(Circle appropriately)
Male/Female                                AA/Al-Anon

Name: ______________________________

Address: ____________________________

City, ST, Zip: ________________________

Phone: __________________


Sobriety Date:                ___________

Dietary Allergies:        ___________

Vegetarian:                ___________
                
* Physical Need:        ___________
* Over 60:        ___________

Name your significant other if attending
Room assignments will be separate
______________________________

These prices are Pre-paid with registration:

TEE SHIRT: $14         How many? _____

S___ M___ L___ XL ___XXL ___ XXXL___

SWEATSHIRT: $20        How many? _____

S___ M___ L___ XL ___XXL ___ XXXL___

                        Amount
Registration:                _______
T-Shirt:                        _______
Sweatshirt:                _______
Total Enclosed:         _______

     *Proceeds from Tee Shirt & Sweatshirt
 Sales Support Scholarships

Make check payable to Roger Slusser

Fill out this form,  include check and mail no later then September 1 to:

Roger Slusser
Fall Mountain Retreat
1811 Patlin Circle North
Largo, FL 33770