Wisdom House
Registration Form
229 East Litchfield Road Litchfield, CT 06759
Office: 860-567-3163 Fax: 860-567-3166


Program Title: ___________________________________________________________________________
Program Date: ___________________________________________________________________________
Please print this registration form, include payment where applicable, and mail to Wisdom House.

Registrations can only be confirmed after receipt of application with a check for full payment. Confirmation also depends on the 'availability' of your selected accommodation. Please choose only an accommodation listed in the details of the program.
___ Shared Room/Hall bath
___ Private or Shared Room w/Bath (limited, give second choice)

Special Dietary Restrictions: (Please check one for yourself and friend, if applicable)
___Vegetarian (No meat or fish) ___ Lactose Intolerance ___ Celiac  

Full payment enclosed _____________________________
Checks are payable to Wisdom House

Mailing Address: ________________________________________________________________________
City: ___________________________________ State: __________________ Zip: ______________
Day Phone: ______________________________
Other Phone: ________________________________
E-mail: (Print Clearly Please) : _____________________________________________________________
Roommate's Name (if requesting a Shared Room): ______________________________________