COR Retreat Registration Form

Please complete the registration form below after submitting your payment.

Your payment secures your place at COR Retreat.

Date of COR Retreat*

First Name*

Last Name*

Gender

Address*

City*

State*

Zip Code*

Phone*

Cell Phone

Email Address*

Emergency Contact Name and Phone*

How would you like your name to read on your name tag?*

Do you have any special needs, dietary restrictions or food allergies? (examples: Vegetarian, no red meat, no dairy, nut allergies, no or low-carb food plan, etc.)

Do you have any physical or mental health issues that we should be aware of? Any disabilities requiring accommodation?

Briefly, what is your experience with Overeaters Anonymous and/or other 12 Step programs?

Please type your name below to accept the terms and conditions outlined below.*

How did you hear about COR Retreat?

If Other, Please Describe:

Payment Information: The registration fee for COR is $1,250 which covers all lodging, meals, and program materials at the retreat. You can pay online at www.cormn.org/register using PayPal or your credit card. If you want to pay by check, send your payment with the completed registration form.

Cancellation Policy: Cancellations must be received by COR Retreat no later than one week prior to the registered retreat date. If you cancel by that time, you may send a substitute, receive a one-year credit memo for another retreat or receive a refund less a $100 cancellation fee. Cancellations made after the one week deadline or failure to attend without notice of cancellation will result in a charge of the full retreat fee. No refunds, credits or transfers for partial attendance will be given. COR Retreat reserves the right to cancel a retreat, in which case registered participants will receive a full value memo for a subsequent retreat or a full refund.

Disclaimer: I understand that COR Retreat does not warrant or agree to effect a cure from the effects of food addiction, but merely agrees to provide me a safe and supportive, mutual-help environment in which to share the principles in the Twelve-Step program of recovery. I understand that COR Retreat provides no clinical and/or counseling services and is not a replacement for a clinical or therapeutic treatment.