11th Step 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: __________________

Email Address:   ______________________________

Sobriety/Serenity Date:                ___________

* Physical Needs, Alergies, Vegitarian, etc... :        
* Over 60:        Y  / N
* Snore  Circle one  Y   /   N
* Smoke/Vape  Circle one  Y   /   N
* Trouble with Stairs  Y   /   N
*Fully Vaccinated for Covid-19   Y / N

Name your significant other if attending
Room assignments will be separate

Semi-Private $255.00
Virtual  $5.00

Registration:                _______
Total Enclosed:         _______


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Make check payable to 11th Step Retreat

Use your browser print button to print this form, fill out the form,  include check and mail no later than August 15th  to:

11th Step Retreat
PO Box 10202
St. Petersburg, FL 33733

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