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
Amount
Registration: _______
Total Enclosed: _______
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