The Union of Psychology and Spirituality Retreat Registration

Registrant Information
Name
Degree
License Number
Address

City
State
Zip
Email Address
Send my confirmation letter:		Email Snail Mail
Receipt Needed?		Yes No

Registration Options (Please Select one )
Single Occupancy	$380 OPA Member/Clergy/Spouse* of OPA Member $425 Non OPA Member $280 Student $320 OPA Member/Clergy/Spouse of OPA Member $365 Non OPA Member $220 Student
Double Occupancy
If double occupancy please choose one: Name of roommate Please assign me a roommate
Dietary restrictions/special needs
Friday Boxed Lunch Options:	Turkey $12.75 Ham $12.75 Vegetarian $12.75 No Lunch Needed
Do you have OPA Member Coupon	If yes amount $
Your card will be charged $

*If your spouse is interested in staying at Mohican, but not participating in the Retreat, contact Heather Gilbert at hgilbert@ohpsych.org about purchasing meals.

Thank you,

Heather Gilbert
Director of Communications and Education
Ohio Psychological Association
395 East Broad Street #310 | Columbus, OH 43215
P: 614-224-0034 | F: 614-224-2059
hgilbert@ohpsych.org

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