Retreat Title: Contact Improv in Paradise
Dates: January 6-13

Your Name:________________________________ Your Email:____________________

Your Home Address:_______________________________________________________

Phone # (hm)___________________________Phone # (cell)_______________________

Passport: Country & #_____________________________; DOB ____________________

How did you hear about this retreat?_________________________________________________

Have you attended any of Moti's workshops before?_______________________

About you (use back of page, if necessary):
____ I have these special dietary needs: _______________________________________
____ I am in excellent health & physical condition.
(If not, please describe your condition on a separate sheet, and your medication.)

In case of emergency, contact (include daytime & evening phone numbers):

_________________________________________________________________________

Occupation &/or vocational passion/dream:

Contact Improvisation Experience:

Dance/Movement Experience:

What do you hope to receive/experience from this retreat:

Room/Board: (check appropriate boxes)
[__] Single room - $540,
[__] Shared room (2-3 person) - $390
[__] Camping (Limited number of camping spaces) - $250

Workshop Fee:
[__] Early Registration (before Nov.1) - $290
[__] (Before Dec.1) - $340
[__] (After Dec.1) - $390

* Minimum of $100 deposit to save space, remainder due by Dec.10

I have enclosed the following payment:
(checks to Mark Zemelman, 12 South Main Street, Haydenville, MA 01039, USA)

$______ deposit

$______ in full payment

Thanks so much. See you in Paradise!