Registration for Concordia Eco Retreat January 2023 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *EmailConfirm EmailAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone number *How did you hear about this Retreat? *Email from Kate Mitcheom / Heart-Based MindfulnessSaw on Kate’s websiteFriend told meOtherPlease explain. Thank you!My accommodation choice is: Double Occupancy ($2050)Single Occupancy ($2680)If Double Occupancy, please select one:I would like to be assigned a roommateI already have a roommateName of my roommateFor rooming assignment purposes, do you identify as *MaleFemaleIf you are not traveling with someone you would like to share a room with, we will pair you with another solo traveler. If no one is available, single occupancy supplement will apply.$150 non-refundable deposit due at time of registrationBalance due Oct 30th, 2023Venmo, Zelle or checks preferred. Credit card also optionalI plan to pay the $150.00 deposit by: *CheckVenmo: @Kate-mitcheomZelle: @Kate MitcheomCredit Card via PayPalYour non-refundable deposit of $150 is due immediately following registration. *I understand that my space is not reserved until Kate Mitcheom receives my check at the address listed below.Please make your $150.00 check payable to Kate Mitcheom and mail to: Kate Mitcheom 17 Haycock Point Road East Branford, CT 06405 Your deposit of $150 via Venmo is due immediately following registration. *I understand that my space is not reserved until Kate Mitcheom receives my Venmo payment. Venmo = @Kate-mitcheomYour deposit of $150 via Zelle is due immediately following registration. *I understand that my space is not reserved until Kate Mitcheom receives my Venmo payment. Zelle = @Kate MitcheomYour deposit of $150 via credit card is due immediately following registration. *I understand that my space is not reserved until Kate Mitcheom receives my credit card payment.After submission of this form, you will be sent to PayPal to complete your payment. Your deposit of $150 via credit card is due immediately following registration. No need to have a PayPal account. You may choose “Pay with debit or credit card” and check out as Guest. Total to be collected by credit card todayPrice: $ 150.00Balance of Retreat reminder *I understand my balance due October 30, 2023.Kindly note that NO REFUNDS will be made. We recommend you consider buying travel protection insurance. Learn moreQuestions or comments? Please share below.I can’t wait to see you in January!Kate NameSubmit