Southern Dharma Retreat Center
         Registration Form


Retreat Dates: ________________________________

Teacher: ______________________________________

Name: _________________________________________

Street: _______________________________________

City: _________________________________________

State: ___________    Zip: ________________

Phone: ________________________________________

Email: ________________________________________

I enclose/debit $ ________ as deposit using

check or (check one): MasterCard ___ Visa ___

If credit card, my account number is

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration Date: Month _____ Year _____

(You can save Southern Dharma more than 3% if you
pay by check rather than credit card.)

I am applying for a scholarship and enclose the $35
processing fee and a short letter of financial need.
I adhere to the scholarship guidelines on the web page
Information about Southern Dharma and Retreats.

I am a: male ___   female ___

I snore: occasionally ___  every night ___

I plan to camp: ___

___ I enclose a $40 donation to become a
    member of Southern Dharma Retreat Center

___ I enclose $ ______ contribution to help
    with the operation of Southern Dharma

___ Please send me information about
    Planned Giving and the Endowment Fund

Print this form & complete. Mail with deposit to

  Southern Dharma Retreat Center
  1661 West Road
  Hot Springs NC 28743