Health Retreat Registration

First Name

Last Name

Street Address

City

State/Province

Zip/Postal Code

Home Phone

Cellphone

Email

Medical Condition

Date of Birth
MonthDayYear

Room Options
(depending on availability)

Sex

Date of Session

Payment Amount

Payment Method

Please note that your registration is not complete until payment has been received.

Please Make Checks out to:
RSHC

Mail Checks to:
Rudolf Steiner Health Center,
1422 W. Liberty St.
Ann Arbor, MI 48103

We will telephone you for credit card information.