Name *

First Name

Last Name

Nickname

First Name

Last Name

Phone *

Country

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###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Travel from Chicago to La Salle Manor Retreat Center *

I am interested in travel options from Chicago to the retreat center.

I am taking care of my own travel plans.

Room Reservation *

Please deduct the Scholarship amount ($100) from the total if your scholarship request has been approved.

Private Room Single Occupancy $375

I would like to donate to a Scholarship (Please add amount to your payment)

$25

$50

$75

$100

Other

Payment Options *

Payments are made separately from registration and can be made through Paypal, Venmo (coming soon) or check. Please email Soberpoz@gmail with questions. Refund policy: June 1 - 17th - 50% refund. Starting June 18th: No refund offered.

I will make my payment through PayPal (See below to Link to SoberPoz PayPal account.)

I will make my payment by check. Email Soberpoz@gmail.com for more information.