Registration – Selah Retreat Spring 2017 Your Name* First Last Email* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Your Beloved's Name*Beloved's Date of Birth* Beloved's Date of Death* Are you currently under psychological/psychiatric care?Are you currently taking medications?YesNoMedication Name and DosageFor how long?In case of emergency, who should we contact?Emergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Email* Enter Email Confirm Email Have you ever meditated?Anything else we should know about you?Make your payment for the retreat below. If for any reason there is a problem or concern with your registration, we will let you know within 72 hours. If you have any questions in the meantime, please check our Selah FAQ's page. We honor you and your beloved and your grief. Cost to register Payment: $615 per person/shared room; $815 per person/private room. If bringing a friend or spouse and registering together, 2-Person Discounted Registration/Shared Room, $1205. If you are able to give more so that another, less privileged, may attend, please contact MISS Foundation, email@example.com. This includes: Lodging for four days, three nights Three delicious pesco-vegetarian meals a day Retreat fee Materials/supplies Select Your Room Type*Shared Room - $615Private Room - $8152-Person Shared Room - $1205Total $0.00 Payment by Credit Card or Check?*I'll pay here with a credit cardI'll send you a checkAbove CC Section StartPlease Provide Your Credit Card Payment Information American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Mid CC Section DividerPlease send your check payable to: MISS Foundation c/o Kelli Montgomery P.O. Box. 9195, Austin TX 78766Below CC Section CloseThere are no refunds after the registration deadline or for withdrawals once a program has begun. Any funds that are created above and beyond the cost of this retreat will go toward the Center for Loss & Trauma/MISS Foundation's family services program to aid individuals and families in acute crisis after the death of a baby or child. This iframe contains the logic required to handle AJAX powered Gravity Forms.