Street Address ___________________________________________
City _____________________________
State ___ Zip ________
E-mail address __________________________________________
Day Phone (area code first) ______
________________________
Cell/Mobile Phone
______ ________________________
Choice of Payment:
__ credit / debit card __ USPS money order
[Circle of Stones Reservation Fee: $100.00 USD to reserve your place in the
gathering of your choice. The remaining $500.00 registration fee is due one
month before the opening date of the gathering of your choice.]
Check which payment you are making when submitting this form:
____ $100 Non-refundable reservation fee
____ $500 Remaining registration fee
Credit or Debit Card Number:
Visa ___________________________________________
MasterCard _____________________________________
Discover ________________________________________
Expiration Date: month __________ year___________
3-digit code after your card # on back of the card _________
Card owner's name exactly as it appears on the credit card:
_______________________________________________
Your reservation payment will appear on your credit card statement as:
PayPal KohlQuest.
Check the dates of the Circle of Stones
gathering you want to attend:
____ October 7 - 10, 2010
Do you have any dietary restrictions (please
be specific)?
________________________________________________________
What mode of transportation will you use
to get to your Circle gathering?
________________________________________________________
By affixing my signature below, I agree to hold harmless KohlQuest, its employees, agents, freelancers,
subscribers, students, or independent contractors against any and all liability, loss, or expense, including
attorney fees, arising directly or indirectly from my participation in the Circle of Stones gathering. I further
acknowledge that I hereby agree to forefeit and forgo ay right of claim or action whatsoever against
KohlQuest, its employees, agents, freelancers, subscribers, students, or independent contractors for
any reason arising from my participation in the Circle of Stones gathering.
_______________________________________________________________________
Signature
Date