Please print this page, fill out form below, send completed registration form (with check or credit card information) to La Casa de Maria, at address shown above.

Make check payable to La Casa de Maria or enter credit card info below.

REGISTRATION FORM  --  Please Print Clearly

Name:_________________________________________________________

Address:______________________________________________________

______________________________________________________________

Telephone #s: Office _(____)__________________________________

Home _(____)___________________ E-mail _______________________

Payment by: [  ]Check   [  ]Visa   [  ]Mastercard

Credit Card No.__________________________ Exp. Date __________

Credit card billing address only if different from address above:

Address:______________________________________________________

______________________________________________________________

Sponsored by
La Casa de Maria Retreat and Conference Centers - Ladera Campus
801 Ladera Lane  --  Santa Barbara, CA 93108  --  (805) 565-9062

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