CIRCLE OF STONES REGISTRATION FORM 
                  
Please Print                                                       

Date _____________

First and Last Name_______________________________________________________

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    __  personal check                                     

Check the payment you are making when submitting this form:

___  $600 (including $100.00 non-refundable reservation 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 registration 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 23- 26, 2014

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


DIRECTIONS:

1.  Print out this registration form.  If you don't have a printer, just write the form information on a plain sheet of paper and mail or fax it with your payment.

2.  Fill in all lines.  Be sure all information you provided is accurate.

3. If you are paying by credit or debit card, double check to be sure you have provided the correct numbers for all the card information requested on the  form.

4. Before mailing your registration form, please include a check or money order made payable to KohlQuest.  Mail your completed registration form with payment to:   KohlQuest, 3271 Polk County Line Road, Rutherfordton, NC, 28139.

5.  Have questions?  Don't hesitate to call KohlQuest at (828) 288-0730 or click here to send us an e-mail.

Thank you for registering!
We look forward to joining you at the Circle of Stones.
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