Qi Gong Registration Form 2107

Mercy & Wisdom Healing Retreat

September 17th 2017 Sunday

Cost: $250                 Time:  9am-5pm

Retreat location: 7411 SE Powell Blvd, Portland OR

Registration Form

Full Name: _____________________________________________

Address: ______________________________________________

Phone: ________________________________________________

Email: ________________________________________________

Medical Concerns:   ______________________________________

_____________________________________________________

Allergies:  _____________________________________________

Emergency Contact: ______________________________________

 Healthy vegetarian lunch provided

                 Call, Send, Email or Fax to: Mercy and Wisdom

mscl1121@gmail.com

7411 SE Powell Blvd. Portland, OR 97206

Phone: 503-762-1122      Fax:  503-762-1155