Annual Housecleaning Retreat
Please print name clearly and
Return with deposit or full payment

                            (Circle appropriately)
Male / Female                        AA / Al-Anon

Name: ______________________________

Address: ____________________________

City, ST, Zip: ________________________

Phone: __________________


Sobriety/Serenity Date:   ___________

Physical Needs:        ___________

Diatary Needs: ___________
(Circle appropriately)
* Over 60: Y  /  N  Trouble Climbing Stairs   Y   /   N
Do you snore  Y  /  N   *Do you smoke/vape    Y    /   N
Covid-19 Vaccinated :  Y / N (required for in-person attendance)
Attending -  In Person    or    Virtual

Name your significant other if attending
Room assignments will be separate
Single Room Y / N      Double Room  Y / N (Circle 1 only)

* No Tee Shirt this year, however we are self-supporting through our own contributions.

Donations for Scholarships are Welcome!

Registration:                _______
Donation:                  _______
Total Enclosed:         _______

God Bless You and Keep You Until We Meet Again

Make check payable to Tom Brown

Use your browser print button to print this form, fill out the form,  include check and mail no later than Feb. 15th to:

Tom Brown/Carmen Leon
Annual Housecleaning Retreat
2118 Cortez Ave
Tampa, FL  33629

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