WOMAN WITHIN WEEKEND REGISTRATION FORM

NAME:

__________________________________________________

ADDRESS LINE 1:

 __________________________________________________

ADDRESS LINE 2:

 __________________________________________________

CITY, STATE, ZIP:

 __________________________________________________

HOME TELEPHONE:

 __________________________________________________

WORK TELEPHONE:

 __________________________________________________

EMAIL ADDRESS:

 __________________________________________________

WEEKEND DATES: (2008)
(SELECT ONE)

____ May 2 - 4, Chicago/Milwaukee (Delavan, WI)

____ June 20 - 22, Columbia,IL

____ Sept 12 - 14, Chicago/Milwaukee (Delavan, WI)

____ Oct 3 - 5, Louisville/Cincinnati (Nazareth, KY)

____ Nov 7 - 9, Chicago/Milwaukee (Delevan, WI)



AMOUNT: ($100.00 TO $650.00)

_________________________ CHECK NUMBER:_________________

MASTERCARD OR VISA
CREDIT CARD NUMBER:

_________________________ EXPIRE DATE:____________________


Confirmation of your registration will be sent upon receipt of your registration form and deposit.
Cancellation Policy:
If you cancel more than 10 days prior to the weekend, you are entitled to a refund of any money already paid, less the $100 non-refundable deposit. This deposit may be transferred to another Woman Within Training weekend sponsored by Woman to Woman Midwest, Inc. within one year from the date of cancellation. If you cancel fewer than 10 days before the weekend, payments received are non-refundable but may be applied to another Woman Within Training Weekend sponsored by Woman to Woman Midwest, Inc. within one year from the date of cancellation.
If you have any questions, contact the registrar at registrar@midwest.womanwithin.org

Financial Support Application
For those in financial need, there are a limited number of tuition discounts available for each training weekend sponsored by Woman to Woman Midwest. In order to be considered for financial support you must include (or have previously submitted) the Woman to Woman Midwest registration form, $100 deposit, and the completed financial support application. The maximum amount of financial support a woman may receive from Woman to Woman Midwest is $200.

SELECT ONE:

____ Yes, I am applying for financial assistance

____ No, I am not applying for financial assistance

SELECT ONE:

____ This is a new registration form.

____ I have previously submitted a registration form.

Please state your reason(s
for applying for financial
assistance:

 __________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

 
Mail to:

Mary Ann Armour
Woman to Woman Midwest
1010 South Carolina St
Louisiana, MO 63353

Fax to Mary Ann Armour:

Fax: 573.754.3880


Phone: 573.754.3131