Online Registration

Date

First and Last Names

Street Address

City, State, Zip Code

E-mail address (for registration confirmation)

Day Phone (area code first)

Cell/Mobile Phone

Use this section is you are paying your $100 USD reservation fee: you may use a credit or debit card.

Visa

MasterCard

Discover

Use this section if you are paying your remaining $500 USD registration fee: you may use a credit or debit card

Visa

MasterCard

Discover

Credit or Debit Card Number

Expiration Date: Month/Year mm/yy

3-digit security code

Full name exactly as it appears on this credit/debit card

Choose the dates of the 2008 Circle of Stones gathering you want to attend:

May 1 - May 4

October 10 - October 13

Do you have any dietary restrictions (please be specific)

What mode of transportation will you use to come to your Circle gathering?

Protecting your personal information is a top priority at KohlQuest. All personal and financial data is protected by advanced SSL encryption. To assure safe, secure and accurate processing of every credit or debit card purchase, KohlQuest has selected PayPal for processing all online transactions. Your registration payment will appear on your statement as a transaction from PayPal KohlQuest.

By submitting this registration form, you 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 your participation in the Circle of Stones gathering. You further acknowledge that you 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 your participation in the Circle of Stones gathering.

Once you have completed the above form and checked to be sure all your information is correct, CLICK ONCE on the SUBMIT button below.


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