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REGISTRATION FORM

 

    Date of Session:                                       

Name                                                                           

Address                                                                       

City                                                                                

State or Province                                                        

Zip or Postal Code                                                     

Phone (home)                                                             

Phone (work)                                                               

E-mail                                                                           

Date of Birth                                                                 

  Room type:                                                                   
     Three meals daily included in session fee

Payment options:                                                       

If you choose to pay by credit card we will call you for the card number. 

Medical services [doctor visits, therapist and nursing] included in session fee. Lab/X-ray via insurance or private pay

We highly recommend a 14- or 21-day stay.  Please arrive Monday morning between 9 and 11.  Please inquire for other lengths of stay. 

10%  Discount for registration 30 days before session begins. 

 

 

Or, highlight, print, and fax or mail this form

Please circle date of session:  July  September   November

Name                                                                                                                           Date of Birth

Address

City

State or Province

Zip or Postal Code

Phone (home)

Phone (work)

E-mail

Date of Birth

Payment options:

[    ] Enclosed Check (payable to CSAM) 

[    ] Visa/MC#

Exp. date (MM/YY)

Signature

Three meals daily included in session fee

Please check one:

[   ]  Double occupancy

[   ]  Single occupancy 

Medical services [doctor visits, therapist and nursing] included in session fee. Lab/X-ray via insurance or private pay

We highly recommend a 14-day stay.  Please arrive Monday morning between 9 and 11 AM.  Please inquire for other lengths of stay. 

10% Discount for registration 30 days before session begins. 

Please send a non-refundable deposit of $1000 to guarantee your room.
Rooms assigned on a first-come, first-served basis. Space is limited to 12 participants.

Please mail enrollment form to:

RSHC Therapeutic Session

1422 W. Liberty

Ann Arbor, MI 48103, USA
 Phone: 866-663-4365  Fax: 734-663-0313

email: rshc@earthlink.net

“To experience the Health Center is like stepping into another world of light and caring...”

--B.B., retreat participant in 2002

 

CSAM was founded in 1997 as a 501 (c) 3 not-for-profit organization dedicated to providing patient care, education and research in Anthroposophical medicine.